tn  tl|?  amg  of  '^m  fork 


Jirnm  tiff  ffithrarg  of 

aityurrlitU  (Earmalt,  it.  1. 

f  rfsfttlfh  bg  tlif  Exttrttf  (Elub  of  Nm  lork 


TUMOURS 

INNOCENT    AND    MALIGNANT 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/tumoursinnocentmOOblan 


PLATE  I.—"  Fungating  "  Sebaceous  Cyst  (Sebaceous  Adenoma)  on 
the  Scalp  of  a  Woman  83  years  of  age.     (.See  paije  237.) 


TUMOURS 


INNOCENT    AND    MALIGNANT 


Stijctr  ©Ixttical  JFeaturj^s  anh  ^pprofrriatc  QTrcatmcnt 


J.   bla:^^d   suttoi^ 

ASSISTANT   SURGEON  TO   THE  MIDDLESEX  HOSPITAL  LONDON 


JFITR    TWO    HUNDRED    AND    FIFTY    ENGRAVINGS    AND 
NINE    PLATES 


PHILADELPHIA 

LEA      BEOTHEES      &      CO 


1893 


PEEFAO  E. 

Very  early  in  the  practice  of  my  profession  I  became  con- 
vinced of  the  great  increase  in  diagnostic  power  that  results 
from,  the  combination  of  pathological  and  clinical  knowledge. 
Imbued  with  this  belief,  I  formed,  eight  years  ago,  the 
intention  of  writing  a  book  on  Tumours  in  which  their 
clinical  and  pathological  features  should  be  equally  considered. 
In  1885  I  began  to  collect  materials,  from  man  and  other 
vertebrates,  in  order  to  make  myself  acquainted  with  the 
histological  peculiarities  of  tumours.  The  great  difficulty 
was  to  define  the  boundaries  of  my  subject.  In  order  to  do 
this  I  determined  to  eliminate  all  those  conditions,  often 
classed  with  tumours,  which  have  been  demonstrated  to 
depend  on  micro-organisms.  This  cleared  the  ground  in  a 
satisfactory  manner.  Attention  was  first  devoted  to  cysts, 
and  the  results  of  the  investigation  were  embodied  in  my 
Hunterian  and  Erasmus  Wilson  Lectures,  delivered  at  the 
Royal  College  of  Surgeons  during  the  years  1886,  '87,  '88,  '89, 
'90  and  '91 ;  they  dealt  particularly  with  the  group  of 
tumours  known  as  Dermoids,  and  the  genus  of  cysts  which 
I  have  ventured  to  name  Tubulo-cysts.  During  the  same 
period  I  contributed  to  the  Odontological  Society  of  Great 
Britain  a  series  of  papers  to  show  that  many  tumours  of  the 
jaws,  vaguely  classed  as  exostoses,  are  really  derived  from 
aberrant  development  of  teeth. 

In  describing  Cancer  a  wide  departure  is  made  from  the 
beaten  track.  The  terms  scirrhus,  colloid,  and  medullary 
or  encephaloid,  have  dominated  the  minds .  of  surgeons 
and  hindered  progress  long  enough.  The  term  cancer  is 
employed  in  a  sense  equivalent  to  malignant  adenoma, 
the  species  being  determined  by  the  gland  in  which  the 
cancer  arises. 

Whenever  it  seemed  desirable  to  illustrate  the  nature  of 
a  genus  of  tumours  by  reference  to  Comparative  Pathology, 
I  have  not  hesitated  to  do  so.    Without  this  aid,  any  attempt 

374782 


vi  TUMOURS. 

to  catch  the  deeper  meaning  of  many  tumours  is  as  difficult 
as  endeavours  to  decipher  a  pahmpsest  in  which  the  first 
characters,  written  in  an  unknown  tongue,  have  been  im- 
perfectly removed  from  the  parchment  and  are  allowed  to 
mingle  with  the  second  inscription. 

In  describing  treatment  it  would  obviously  be  out  of 
place  to  give  the  details  of  operations  in  a  work  of  this  kind, 
so  I  have  contented  myself  by  indicating  the  principles. 

In  selecting  the  figures  every  effort  has  been  made  to 
avoid  depicting  repulsive  coriditions.  To-day  surgeons  are 
much  more  interested  in  studying  the  Biology  of  Tumours 
than  in  recording  their  weight.  As  the  Surgery  of  Tumours 
is  far  safer  than  in  the  first  half  of  this  century,  patients,  now 
thoroughly  aware  of  this,  submit  to  operations  at  an  early 
date.  The  more  this  is  recognised,  and  the  more  generally 
the  impotence  of  drugs  when  employed  against  tumours  is 
realised,  the  more  successful  will  the  Surgery  of  Tumours 
become. 

I  have  to  thank  Mr.  T.  Carwardine  for  kindly  reading  the 
proof-sheets,  Mr.  C.  Berjeau  for  his  excellent  drawings,  and 
Mr.  C.  Butterworth  -for  many  admirable  examples  of  wood- 
engraving. 

In  a  systematic  work  of  this  kind  it  follows  that,  in  order 
to  find  descriptions  of  the  various  tumours  to  which  an  organ 
is  liable,  the  reader  must  refer  to  clifterent  sections  of  the 
book.  To  minimise  this  disadvantage  I  have  made  two 
special  indexes — one  showing  the  tumours  to  which  an  organ 
is  liable,  and  the  other  indicating  the  distribution  of  tumours 
among  the  organs ;  hence  these  constitute  a  syllabus  rather 
than  a  mere  Index. 


J.  BLAND  SUTTON. 


48,  Queen  Anne  Street, 

Cavendish  Square,  W. 
October,  1893. 


CO]SrTE]N"TS 


PAGE 

Classification      ........        1 

CHAPTER    I. 

Group  I.— Connective  Tissue  Tumours        .  .  .  .3 

CHAPTER    II. 

Chondromata  (Cartilage  Tumours)  .  .  .  .  .17 

CHAPTER    III. 

OSTEOMATA   (OsSEOUS   TUMOURS)  .  ■     .  .  .  .23 

CHAPTER    IV. 

Odontomata  (Tooth  Tumours)  .         .  .  .  .  .31 

CHAPTER    V. 
Fibromata  .  .  .  .  .  .  .  .  .49 

CHAPTER    VI. 
Myxomata  .........      59 

CHAPTER    VII. 
Gliomata    .........       63 

CHAPTER    VIII. 
Sarcomata  .........      67 

CHAPTER    IX. 

Sarcomata  [continued)     .......      78 

CHAPTER    X. 

Sarcomata  [continued)     .  .  .  .  .  .  .90 

CHAPTER    XI. 

Sarcomata  [continued)     .......      96 

CHAPTER    XII. 

Sarcomata  [continued]     .  .  .  .  .  .  .  ■  104 

CHAPTER    XIII. 

Sarcomata  [continued]     .......     108 

CHAPTER    XIV. 

Sarcomata  [concluded]     .......     117 


viii  TUMOURS. 

CHAPTER    XV.  PAoi: 

Myomata    .  .  .  .  .  •  •  .120 

CHAPTER    XVI. 

Neuromata  .  .  .  ■  •  •  •  .147 

CHAPTER    XVII. 
Angeiomata  ........     158 

CHAPTER   XVIII. 
Group  II. — Epithelial  Tumours— Papillomata     .  .  .167 

CHAPTER    XIX. 
Papillomata  {concluded).  ......     177 

CHAPTER    XX. 
Cutaneous  Horns  .  .  .  .  •  •  .183 

CHAPTER    XXI. 
Epithelioma  .  .  .  .  .  -  .  .191 

CHAPTER    XXII. 

Epithelioma  {concluded) .......     207 

CHAPTER    XXIII. 

Adenoma  and  Carcinoma         ......    218 

CHAPTER    XXIV. 

Cysts,  Adenoma,  and  Carcinoma  of  Sebaceous  and  Mucous 

Glands.  ........     233 

CHAPTER    XXV. 

Adenoma  and  Carcinoma  of  the  Thyroid,  Prostate,  Parotid, 
and  Pancreas  .  .  .  .  .  •  .    240 

CHAPTER    XXVI. 

Adenoma  and  Carcinoma  of  the  Liver,  Kidney,  Ovary,  and 
Testicle  ........    250 

CHAPTER    XXVII. 

Adenoma  and  Carcinoma  of  the   Stomach,   Intestines,   and 
Rectum  .  .  .  .  .  •  •  •     259 

CHAPTER    XXVIII. 

Adenoma  and  Carcinoma  of  the  Uterus  and  Fallopian  Tube    272 

CHAPTER   XXIX. 

Group  III.— Dermoids     .......     279 


CONTENTS.  ix 

CHAPTEK    XXX.  page 

Sequestration  Dermoids  [contiimcd)  .  .  .  .  .     287 

CHAPTER    XXXI. 

Sequestration  Dermoids  {concluded)  .....     299 

CHAPTER    XXXII. 

Implantation  Cysts       .......     304 

CHAPTER    XXXIII. 
Tubulo-Dermoids.  .......     308 

CHAPTER    XXXIV. 

Tubulo-Dermoids  [continued)     ......    318 

CHAPTER    XXXV. 

Tubulo-Dermoids  {concluded)    ......     323 

CHAPTER    XXXVI. 
Dermoids    .........     330 

CHAPTER    XXXVII. 

Dermoids  {concluded)        .  .  .  .  .  .  .     339 

CHAPTER    XXXVIII. 

Peculiarities  in  the  Distribution  of  Cutaneous  Appendages     « 
IN  Dermoids  ........     346 

CHAPTER    XXXIX. 
Moles         .........    353 

CHAPTER    XL. 
The  Treatment  of  Dermoids  ......    359 

CHAPTER    XLI. 
Teratomata  .  .......     363 

CHAPTER    XLII. 
Group  IV.— Cysts  .......    376 

CHAPTER    XLIII. 
Tubulo-Cysts        ........     389 

CHAPTER    XLIV. 

Tubulo-Cysts  {conchuh:!)  .  .  .  .  .  .397 

CHAPTER    XLV. 
Hydrocele.  .  .  .  .  .  .  .  .411 


X  TUMOURS. 

CHAPTER    XLVI.  page 

Congenital  Cysts  (Hydroceles)  of  the  Neck  and  Axilla      .    419 

CHAPTER    XLVII. 

Cysts  of  the  Salivary  Glands— Ranul^— Pancreatic  Cysts— 

Dacryops         ........     425 

CHAPTER    XLVIII. 
Pseudo-Cysts        ........    431 

CHAPTER    XLIX. 
Neural  Cysts       ........    445 

CHAPTER    L. 
Neural  Cysts  {concluded)  .  ...  .  .  .     459 

CHAPTER    LI. 
Hydatid  Cysts     ........    472 

CHAPTER    LII. 

The  Zoological  Distribution  of  Tumours  ....    487 

CHAPTER    LIII. 

The  Cause  of  Tumours.  .  .  ...  .  .    492 


LIST    OF    ILLUSTEAT10E"S. 


Lipoma  in  the  palm  of  the  hand     . 

Lipoma  of  the  left  axilla     . 

Lipoma  superhcial  to  the  temporal  fascia. 

Diffuse  lipoma  of  the  neck . 

Small  pendulous  appendices  epiploicte,  Avith  twisted  pedicles,  of  the 

ascending  colon  ..... 

Lipoma  arborescens  of  the  shoulder 

Enlarged  sucking-cushion  ..... 
Emaciated  child  crying  and  displaying  the  sucking-cushion 
Meningeal  lipoma  simulating  a  spina  bifida  in  a  chihl  eight  months 

old  .  .  . 

Meningeal  lipoma  overlying  the  sac  of  a  sj)ina  bifida 
Lad  twenty  years  of  age  with  multiple  chondromata 


Condyles  and  epiphysial  line  of  a  rickety  femur,  with  a  cartilage  island       19 
Osteoma  of  the  left  frontal  sinus  (anterior  view)  .  .  .24 

Osteoma  of  the  left  frontal  sinus,  seen  from  below  .  .  .24 

Exostosis  of  the  femur  :  its  surface  w^as  clad  with  cartilage  and  sur- 
mounted by  a  bursa     .  .  .  .  .  .  .26 

Symmetrical  exostoses  of  the  nasal  processes  of  the  maxilhe     .  .       27 

Big  toe  with  a  sub-ungual  exostosis  .  .  .  .  .28 

Bell's  specimen  of  Chmtodon,  with  its  bony  tumours  and  large  occipital 

crest       .........       29 

Epithelial  odontome  .......       31 

Microscopical  characters  of  an  epithelia,l  odontome         .  .  .32 

Follicular  odontome  (dentigerous  cyst)    ...  .  .  .33 

Fibrous  odontome  from  a  goat       .  .  .  .  .  .33 

Cementome  from  a  horse     .  .  .  .  .  .  .34 

Compound  follicular  odontome  from  a  Thar  (Co^jrrtye»)^a{c«)    .  .       35 

Denticles  from  the  odontome  of  a  Thar    .  .  .  .  .36 

Denticles  from  Tellander's,  from  Sims's,  and  from  Mathias's  cases       .       37 
Radicular  odontome  from  human  subject .  .  .  .  .38 

Radicular  odontome  .  .  .  .  .  .  .39 

Left  lower  jaw  of  a  young  marmot  with  a  large  radicular  odontome 

connected  with  the  incisor       .  .  .  .  .  .39 

Lower  jaAV  of  an  adult  Canadian  porcupine  :  a  radicular  odontome  is 

attached  to  its  lower  incisor    .  .  .  .  .  .40 

Two  figures  of  a  radicular  cementome  from  a  man  aged  twenty-five 

years      .........       40 

Composite  odontome  from  a  young  lady  aged  eighteen  .  .  .41 

Composite  odontomes  .  .  .  .  .  .  42  &  43 

Odontome  from  the  upper  jaw        .  .  .  .  .  .43 

Composite  odontome  from  the  upper  jaw .  .  .  .  .44 

Large  odontome,  which  Avas  spontaneously  shed  from  the  antrum  .       46 

Section  of  large  odontome  to  show  the  concentric  lamination    .  .       46 

Composite  odontome  from  the  upper  jaw  :  the  left-hand  figure  shows 

tlie  tumour  in  section  .  .  .  .  .  .  .47 

Odontome  from  the  upper  jaw        .  .  .  .  .  .47 

Case  of  molluscum  fibrosum  .  .  ...  .  .53 

Native  of  Sierra  Leone,  aged  fifty,  with  molluscum  fibrosum     .  .       55 

Keloid  in  the  lobule  of  the  pinna,  associated  with  an  ear-ring  puncture      56 
Unusual  case  of  keloid  in  a  coloured  woman        .  .  .  .57 


6 

7 

9 
10 

12 
12 

14 
15 
18 


xii  TUMOURS. 

PAGE 

Pediinciilated  myxoma  from  tlie  labiuiri  of  a  woman  fifty  yearn  olfl      .       61 
Bilateral  giiomatous  enlargement  of  the  pons  and  crura  cerel)ri  .       65 

Spinal  cord,  in  transverse  section,  from  a  case  of  glioma  .  .       66 

Microscof)ical  appearance  of  a  lympho-sarcoma  from  the  mediastinum       68 
Small  spindle-celled  sarcoma  from  a  metacarpal  bone     .  .  .68 

Cells  from  a  spindle-celled  sarcoma  of  the  neck  of  the  uterus     .  .       69 

Myeloid  sarcoma  from  the  acomial  end  of  the  clavicle    .  .  .71 

Periosteal  sarcoma  of  the  ilium  invading  the  inferior  vena  cava  .       75 

Sjjina  ventosa  of  the  fibula  .  .  .  .  .  .80 

Skeleton  of  an  ossifying  periosteal  sarcoma  of  the  femur  .  .       81 

Spindle-celled  sarcoma  ot  the  fibula  .  .  .  .  .83 

Sarcoma  arising  in  the  follicle  of  a  developing  tooth       .  .  .86 

Deformity  produced  by  a  sarcoma  of  the  nasal  septum  .  .  .87 

Faciar region  of  the  skull  from  the  case  shown  in  the  preceding  figures, 

seen  in  sagittal  section  .  .  .  .  .  .88 

Parotid  sarcoma  implicating  the  pinna  in  a  woman  thirty-five  years  of 

age         .........       91 

Microscopical  characters  of  a  tumour  arising  in  an  accessory  adrenal   .       99 
Kenal  tumour  originating  in  an  accessory  adrenal  .  .  .     100 

Myo-sarcoma  of  the  testis  .......     101 

Portion  of  a  mediastinal  lympho-sarcoma,  to  show  the  manner  in  ^^'hich 

the  tumour  extends  along  the  bronchi  and  pulmonary  vessels  .  105 
Anterior  portion  of  a  dace  ;  each  black  spot  contains  a  central  white 

dot  representing  an  encysted  parasite  ....     109 

Pigmented  mole   which   ulcerated  and   infected  the  inguinal  lymph 

glands  ;  the  patient  was  sixty-five  years  of  age         .  .  .111 

Melano-sarcoma  of  the  uveal  tract  .....     113 

Secondary  nodules  of  melano-sarcoma  in  the  liver  .  .  .114 

Forearm  of  a  woman  four  years  after  excision  of  the  lower  fourth  of 

the  ulna  and  the  radius  for  a  myeloid  sarcoma  of  the  radius  .     118 

Section  of  a  uterus  showing  a  small  myoma  ....  128 
Very  vascular  uterine  myoma  seen  in  section  ....  129 
Microscojsical  appearance  of  the  mucous  membrane  covering  a  prolapsed 

uterine    myoma,    showing    mutation   of   columnar   ciliated  into 

stratified  epithelium  as  a  result  of  pressure  ....     130 

Section  of  a  litems  with  multiple  myomata  ....     132 

Myoma  of  the  broad  ligaments       ......     140 

Myoma  of  the  Fallopian  tube         ......     142 

Congenital  subcutaneous  myoma  of  the  occiput  ....     144 

Neuroma  of  the  infra-orbital  nerve  invading  the  antrum  .  .     148 

Neuro-fibroma  of  the  radial  nerve  at  the  wrist,  from  a  female  nineteen 

years  old  .  .         '    .  .  .  .  .  .     149 

Plexiform  neuroma  from  the  back  of  a  youth  nineteen  years  of  age  .  152 
Arm  in  which  the  musculo-spiral  nerve  was  neuromatous  .  .     153 

The  arm  represented  in  the  jjreceding  figure  dissected  ;  the  musculo- 
spiral   nerve  and  its  branches  are.  transformed  into  a  plexiform 

neuroma  ........     154 

Dissection  of  a  stump  of  the  forearm  three  years  after  amputation,  to 

show  the  bulbs  on  the  ends  of  nerves  .  .  .  .     155 

Dissection  of  a  plexiform  angeioma  of  the  forehead        .  .  .163 

Macroglossia  in  a  girl  aged  eleven  years  .....     166 

Wart  growing  from  the  skin  of  the  cheek  and  obscuring  the  eye  .     169 

Microscopical  characters  of  the  wart  in  the  preceding  figure      .  .     170 

Wart-horn  growing  on  the  pinna  .  .  .  ...  .172 

Villous  tumour  of  the  bladder        .  .  .  .  .  .173 

Pelvis  of  a  kidney  with  a  villous  papilloma  .  .  .  .174 

Section  of  a  mamma  with  a  dilated  duct  filled  with  villous  papillomata  176 
Microscopical  appearance  of  a  typical  psammoma  .  .  .177 

Bilateral  psammomata  in  relation   with   the   lateral  recesses   of   the 

fourth  ventricle  .......     178 

Psammomata  in  the  lateral  ventricle  of  a  horse's  brain  .  .  .     180 


LIST    OF    ILLUSTRATIONS.  xili 

PAGE 

Portion  of  the  spinal  cord  with  a  psammoma        .             .             .             .  ISl 

Cutaneous  iiorn  :  the  widow  Dinianche     .              .             .             .             ;  183 

Cutaneous  horn  from  the  penis       .  .  .  .  .  .184 

Sebaceous  liorn  in  a  mouse  .  .  .  .  •  .185 

Head  of  an  African  rhinoceros  with  a  large  wart  posterior  to  and  in  a 

line  with  its  nasal  horns           ......  186 

Head  and  leg  of  a  thrush  with  cutaneous  horns  ....  187 

Horn  formed  on  the  cicatrix  of  a  burn      .  .  .  .  .188 

Horns  growing  from  the  scar  of  a  burn      .....  189 

Epithelioma  of  the  upper  lip  (early  stage)            ....  191 

Epithelioma  of  the  lip,  beginning  in  a  fissure       ....  192 

"  Warty  "  variety  of  epithelioma  ......  193 

Microscopic  appearance  of  the  cells  in  epithelioma :    the  connective 

tissue  stroma  is  omitted            ......  194 

Epithelioma  of  the  gall  bladder      ......  216 

Section  of  an  adenoma  from  a  child's  rectum        ....  219 

Cancer  of  the  breast             .             .             .            .             .             .             .  223 

Section  from  a  mammary  cancer    .             .              ....  224 

Sebaceous  glands  in  the  velvet  of  the  antler  of  a  stag     .             .             .  234 

Large  sebaceous  adenoma  involving  the  pinna     ....  236 

Large  unilateral  bronchocele           .             .             .             .             .             .  241 

Bronchocele  of  unusual  size             .             .             .             .             .             .  242 

Pulsating  tumour  of  the  skull,  associated  with  an  enlarged  thyroid       .  243 

Microscopical  appearance  of  the  tumour  of  the  skull  in  preceding  figure  244 

Median  prostatic  adenoma,  sketched  from  -N^-ithin  the  bladder    .             .  246 
Adenoma  of  the  liver           .... 

Congenital  cystic  kidney     .... 

Congenital  cystic  kidney :  early  stage 
Adenoma  of  the  kidney       .... 

Sorcalled  colloid  of  the  mentum     . 

Cancer  of  the  sigmoid  flexure  of  the  colon 

Cancer  of  colon  (constricting  variety) 

Section  of  three  thoracic  ^'ertebrce,  with  a  small  dermoid  situated  over 

two  stunted  spinous  processes. 
Dermoid  in  the  lumbo-sacral  region  of  a  man  tM'enty-tw 

Median  aspect  of  a  sheep's  digit,  showing  the  interdigital  pouch            .  282 
Dermoid  situated  over  the  junction  of  the  manubrium  and  gladiolus  of 

the  sternum  :    there  was  also  a  dermoid  near  the  left  corner  of 

the  hyoid  bone  .             .             .             .             .    -        .             .             .  283 

Presternal  dermoid  ........  284 

Sternal  dimple          ........  285 

Head  of  an  early  human  embryo,  showing  the  disposition  of  the  facial 

fissures.              ........  287 

Mandibular  tubercle  associated  Avith  a  malformed  auricle           .             .  288 
Right  side  of  the  head  of  a  foetus,  showing  a  large  mandibular  tubercle 

and  an  accessory  tragus            ......  289 

Pierrot's  head,  to  show  the  mandibular  tubercle  ....  290 

Median  fissure  of  the  lower  lip       .             .             .             .             .             .  291 

Congenital  fistulfe  in  the  lower  lip  of  a  child,  associated  with  double 

hare-lip  .........  292 

Haredip  in  a  frog,  associated  with  a  persistent  intermandibular  fissure  293 

Dermoid  at  the  outer  angle  of  the  orbit    .....  294 

Dermoid  at  the  inner  angle  of  the  oi-bit     .....  295 

Dermoid  arising  in  naso-facial  sulcus        .....  296 

Nasal  dermoid  in  a  child     .......  297 

Pedunculated  dermoid  tumour  from  the  pharyngeal  aspect  of  the  soft 

palate     .........  298 

Dermoid  of  the  scalp  connected  by  a  pedicle  with  the  dura  mater          .  299 

Head  of  the  man  Lake  with  a  large  dermoid        ....  300 

Congenital  tumour  over  the  anterior  fontanelle   ....  301 

Implantation  cyst  from  the  tip  of  the  finger         ....  304 


250 
253 
254 
255 
261 
264 
265 


280 
o  years  of  age .  281 


xiv  TUMOUBS. 

PACK 

Large  implantation  cyst  of  the  cornea,  following  an  injnry        .             .  306 

Section  of  the  cyst  in  the  preceding  figure,  highly  magnified      .             .  307 

Large  lingual  dermoid,  protruding  from  the  mouth  .  .  .  310 
Diagram  to  show  the  relation  of  parts  in  a  case  of  median  cervical 

fistula     .........  314 

Thyroid-dermoid      .........  319 

Thyroid-dermoid  of  the  coccygeal  region,  in  section        .             .             .  320 

Rectal  dermoid  in  section   .             .             .             .             .             .             .  321 

Rectal  dermoid         ........  322 

Early  mammalian  embryo,  showing  the  gill-clefts            .             .             .  323 

Diagram  to  indicate  the  orifices  of  persistent  branchial  fistuke  .             .  324 

Pharyngeal  diverticulum     .......  327 

Head  and  neck  of  a  young  woman,  showing  branchial  fistuhe  in  the 

neck  and  a  sinus  in  the  helix  .              .....  328 

Cervical  auricles  in  a  child.             ......  330 

Head  and  neck  of  a  goat  with  cervical  auricles    ....  331 

Horned  sheep  with  cervical  auricles          .....  332 

Head  of  a  pig  with  cervical  auricles  (the  Bell-pig  of  Australia) .             .  333 

Faun  and  goat  with  cervical  auricles         .....  334 

Two  drawings  representing  the  development  of  the  auricle        .             ,  335 

Congenital  fistula  in  the  helix         ......  336 

Dermoid  of  the  auricle  and  naevus  of  the  palpebral  conjunctiva.             .  337 

Auricle  with  an  accessory  trajus    ......  338 

Mucous  membrane  from  an  ovarian  dermoid        ....  340 

Ovarian  dermoid  detached  from  the  uterus  and  hanging   from   the 

omentum            ........  342 

Ovum  in  its  follicle  :  from  a  cat     ......  345 

Magnified  section  of  an  ovarian  dermoid,  to  show  the  large  size  of  the 

sebaceous  glands            .......  346 

Ovarian  dermoid  with  a  sebaceous  gland,  from  a  woman            .             .  347 

Ovarian  mamma  :  hair  and  teeth  are  also  present            .             .             .  348 

Head  of  a  sheep  Avith  a  branchial  fistula,  cervical  auricle,  and  tooth     .  349 

The  germ  of  an  ovarian  tooth,  from  a  dermoid     ....  350 

Epithelial  pearl        .  .  .  .  .  .  .  .351 

Extensive  hairy  mole  upon  the  face  of  a  boy  a  year  old  .  .  353 
Extensive  hairy  mole  on  the  trunk  of  a  man  forty-seven  years  of  age, 

which  became  the  seat  of  sarcoma,  from  which  the  patient  quickly 

died        .........  354 

Conjunctival  mole  :  common  variety         .....  356 

Mole  on  the  caruncle,  associated  with  an  eccentric  pupil  .  .  356 
Conjunctival  mole  associated  Avitli  coloborna  of  the  eyelid,  a  mandibular 

tubercle,  and  accessory  tragus             .....  357 

Conjunctival  mole  in  a  sheep          ......  358 

The  tAvin-sisters  Radica  and  Doodica  at  the  age  of  three  and  a  half 

years      .........  363 

Laloo,  a  Hindoo,  with  an  acardiac  parasite  attached  to  his  thorax  .  364 
Chick  with  a  supernumerary  pair  of  legs  projecting  from  the  ventral 

aspect  of  the  pelvis       .......  365 

Chick  with  a  supernumerary  pair  of  legs  projecting  from  the  dorsal 

aspect  of  the  pelvis       .......  365 

Frog  {Rami  palustris)  Avith  a  supernumerary  hind-leg     .             .             .  366 

Louise  I.,  dame  a  quatre'jambes     ......  367 

Sacral  teratoma  with  a  supernumerary  leg            ....  368 

Posterior  view  of  J.  B.  dos  Santos  at  the  age  of  six  months        .             .  369 

Cephalic  extremity  of  a  two-headed  snake            ....  370 

Acardiac  foetus  .  .  .  .  .  .  .  .371 

Acardiac  foetus         ........  372 

Acardiac  in  Fig.  191  shown  in  section        .....  373 

Young  toad  with  a  supernumerary  hind-limb       ....  374 

Section   through   the   tip   of   the   vermiform   appendix,    to   show  the 

abundance  of  its  glands            ....                         .  378 


LIST    OF    ILLUSTRATIONS.  xv 

PAGE 

Hyilroneplirosis   secondary  to  a  large  calculus  in  the  bladder :    two 

fragments  of  calculus  occupying  the  prostatic  portion  of  the  urethra  379 
Bilateral  hydronephrosis  in  a  new-born  child  ....  380 
Calculus  impacted  in  the  urethra  of  a  gelding,  producing  Avide  dilata- 
tion of  the  vesical  orifices  of  the  ureters  and  double  hydronephrosis  382 
Unilateral  (intermitting)  hydronephrosis  .....  383 
Pyonephrosis  of  one-half  of  a  horse-shoe  kidney  .  .  .  .  ,384 
Concretions  from  the  guttural  pouches  of  horses  ....  388 
Congenital  jjedunculated  tumour  of  the  navel  .  .  .  .  389 
Diagram  of  the  alimentary  canal  of  the  embryo,  showing  the  position 

of  the  yolk  sac  ........  390 

Cyst,  probably  of  the  vitello-intestinal  duct,  attached  to  the  intestine 

of  an  emu           ........  392 

Septate  ileum            ........  393 

Ileum  with  a  persistent  vitello-intestinal  duct  associated  with  a  valve.  394 

Imperforate  ileum    ........  395 

Diagram  to  represent  the  cyst  regions  of  the  ovary          .             .             .  398 

Ruptured  papillomatous  (paroophoritic)  cysts  of  the  ovary         .             .  399 

Cyst  of  the  parovarium,  .showing  its  relation  to  ovary  and  tube  .  402 
Anterior  portion  of  a  cow's  vagina,  showing  two  large  cysts  developed 

in  the  terminal  segment  of  Gartner's  duct  ....  403 
Diagram  to  show  the  relation  of  the  mesonephros  and  its  ducts  to  the 

adult  testicle     ........  404 

Hydrocele  of  the  tunica  vaginalis,  and  an  encysted  hydrocele  associated 

with  the  same  testis      .......  405 

Testicular  adenoma             .......  408 

Hydrocele  of  the  tunica  vaginalis  testis     .....  412 

Ovarian  hydrocele  in  a  rat .             ......  416 

Ovarian  hydrocele  :  the  interior  of  the  sac  is  bent  with  warts    .             .  417 

Congenital  cervical  cyst  extending  into  the  axilla            .             .             .  420 

Congenital  cervical  cyst  in  a  man  tA\-enty  years  of  age    .             .             .  421 

Congenital  cyst  of  the  thorax  with  nevoid  walls.             .             .             .  422 

Imperforate  pharynx            .......  433 

Septate  pharynx       ........  434 

Pharyngeal  diverticulum     .......  4.35 

Tracheal  opening  and  pouch  of  an  emu    .....  436 

Bursa  under  the  semi-membranosus  tendon  communicating  with  the 

knee-joint          ........  4.38 

Hydrocephalic  skull,  from  an  infant          .....  445 

Hydrocephalic  skull,  showing  Wormian  bones     ....  446 

Sagittal  section  of  a  hydrocephalic  skull  from  a  child,  with  the  brain 

in  situ    .........  447 

DraAving  from  a  cast  of  the  head  of  James  Cardinal  .  .  .  449 
Head  of  a  lion's  whelp  in  section,   showing  great  dilatation  of  the 

cerebral   ventricles,    due  to   obstruction   of    the  interventricular 

passages  by  a  thickened  (rickety)  tentorium              .             .             .  4.50 

Hydrocele  of  the  fourth  ventricle  ......  451 

Occipital  meningo-encephalocele    ......  4.52 

Boy  with  a  cephalhfematoma  over  the  right  parietal  bone          .             .  455 

Monkey  (Cebns  monachus)  with  a  huge  cephalhfematoma  .  .  456 
Skull   of   Cehus  monachus,   showing  the   bony  Avails  of  the    cephal- 

ha?,matoma  and  a  group  of  Wormian  bones  ....  457 

Lumbar  region  of  a  fretus  Avith  spina  bifida,  variety  myelocele  .  459 
Diagram    to   represent  the    microscopic    characters   of   a  transverse 

section  of  a  myelocele .             .             .             .             .             .             .  460 

Syringo-myelocele  in  transverse  section   .....  461 

Syringo-niyelocele  and  meningocele  in  longitudinal  section  :  from  the 

cervical  region  ........  462 

Diagram  shoAving  meningo-myelocele  in  transverse  section  .  .  463 
Microscopical   appearances   of   the  nerve-tissue   from  the   Avail   of   a 

meningo-myelocele  showing  the  central  canal           .             .             .  464 


xvi  TUMOURS. 

PAOE 

African  child  with  a  pedunculated  tumour  (an  occlu'led  spina  bifida 

sac)  attached  to  its  buttock     ......  465 

Tumour  from  the  African  child  (.s.38  previous  ligure),  shown  in  section  466 

Hair  field  on  the  loin  overlying  a  spina  bifida  occulta     .             .             .  467 
Hair  field  overlying  a  spina  bifida  occult.i ;  there  is  also  a  long  tuft  on 

the  cervical  region        .             .                          ....  46S 

^gipan  sporting  with  a  faun  [Bacchus  and  Silenus)        .             .             .  469 

Half- vertebra            ........  470 

Echinococcus  colony  in  the  kidney             .             .             .             .             .  473 

Multilocular  hydatids  of  the  shaft  of  the  humerus          .             .             .  474 
Multitude  of  minute   hydatids   on   the   pelvic  peritoneum,   probaldy 

secondary  to  the  tapping  of  a  cyst  in  the  liver          .             .             .  477 

Cyst  (implantation)  of  the  palm   ......  498 


LIST    OF    PLATES. 


"Fungating"  Sebaceous  Cyst  (Sebaceous  Adenoma)  on 

the  scalp  of  a  woman  eighty-three  years  of  age  .  Froutispiece 

Melanosis   of  the   Skin,  secondary  to   Melano-sarcoma 

of  the  Uveal  Tract        .....    To  face  i^uge     114 
Molhrscum   Fibrosum   combined   with   tumours   on   the 

nerves     .  .  .  .  .  .  .  ,,  150 

An  unusual  form  of  Wart,  growing  from  the  skin  of  the 

Pubes     .......  ,,  170 

Cuirass  Cancer.     The  right  breast  had  been  amjjutated 

two  years.    The  right  arm  is  in  the  condition  kuo^vn 

as  "Lymphatic"  G^ldema        .  .  .  .  ,,  227 

Inflamed  Sebaceous  Cyst,  situated  on  the  inner  margin  , 

of  the  Left  Mamma       .  .  .  .  .  ,,  2.35' 

Placenta  from  a  case  of   Twins,   one  of  Avhich  was  an 

Acardiac  •-  .  .  .  •  .  ,,  374 

Right  Kidney  with  Two  Ureters,   one  of  which  opens 

into  the  Bladder  at  the  vesical  orifice  of  the  Urethra  ; 

the  lower  half  of  the  kidney  drained  by  this  ureter 

is  converted  into  a  pyonephrosis.      The  upper  half 

drained  by  the  normal  m'eter  is  healthy.     The  left 

kidney  was  normal         .  .  .  .  .       •        ,,  385 

Lower  two-thirds   of  a  Femur,  with  the  upper  fourths 

of  the   Tibia   and   Fibula.     The   remnants    of  the 

Femur  and  Tibia  are  fenestrated  osseous  shells,  in 
•  consequence  of  the  pressure  exercised  by  multilocular 

hydatids   Avhich  began  in  the  Femur,  invaded  the 

Knee-joint   and  involved    the  Tibia.      There  is   a 

sequestrum  in  the  Femur  measuring  7  "5  cm.  by  4  cm.  ,,  482 


TUMOUES 

INNOCENT    AND    MALIGNANT: 

Their   Clinical   Characters   and   A])pTopriate   Treatment. 


CLASSIFICATION. 

Any  thoughtful  individual,  on  commencing  the  study  of 
tumours,  must  doubtless  have  been  struck  by  the  confusion 
which  prevails  in  oncological  literature  in  regard  to  the  use 
of  such  terms  as  classes,  groups,  species,  varieties,  etc.  This 
confusion  will  be  more  obvious  if  the  student  be  acquainted 
even  in  a  moderate  degree  with  Systematic  Zoology.  Not 
that  the  zoologist  can  in  any  way  claim  to  have  discovered 
a  perfect  method  of  classification,  but  he  certainly  uses  the 
terms  genus,  species,  etc.,  in  a  consistent  manner. 

In  the  present  work  an  attempt  will  be  made  to  classify 
tumours  on  similar  lines  to  those  employed  in  Biology.  The 
classification  adopted  is  one  which  will  not,  in  any  serious  way, 
involve  the  Taxonomy  (if  it  be  worth  such  a  name)  at  present 
in  fashion. 

It  is  certain  that  the  efforts  of  J.  Miiller  (1838)  to  classify 
tumours  according  to  their  minute  structure  had  a  great  in- 
fluence in  promoting  the  study  of  Oncology.  Virchow's  labours 
on  the  histolog)^  of  tumours,  and  especially  his  success  in  de- 
monstrating that  all  the  tissues  found  in  them  have  a  physio- 
logical prototype,  have  made  it  plain  that  it  is  impossible,  in 
any  useful  classification  of  tumours,  to  neglect  to  take  into 
consideration  their  structural  characters. 

To-day  it  must  be  clear  to  all  who  study  Virchow's  great 
work,  "Die  Krankhaften  Geschwlilste"  (1863),  in  the  light  of  our 
present  knowledge  that  he  employed  the  term  tumour  in  a 

B 


2  TUMOURH. 

too  comprehensive  manner.  It  is  highly  desirable  to  exclude 
from  tumours  those  formations  known  as  infective  granido- 
mata,  and  there  can  be  no  doubt  that  this  group  will  be 
largely  increased  in  the  near  future,  as  it  has  been  in  the 
recent  past,  at  the  expense  of  sarcomata  and,  in  all  probability, 
of  the  epitheliomata  and  carcinomata,  as  our  knowledge  of  the 
biology  of  micro-organisms  increases. 

Tumours  may  be  arranged  in  four  groups  : — 

I.  Connective  tissue  tumours. 
II.  Epithelial  tumours. 

III.  Dermoids. 

IV.  Cysts. 

Each  group  contains  several  genera  ;  each  genus  has  one  or 
more  species  ;  of  each  species  there  may  be  one  or  more 
varieties. 


CHAPTER  I. 

GROUP    I.— CONNECTIVE    TISSUE    TUMOURS. 

The    Connective    Tissue    Group    of    tumours    contains    the 
following  genera : — 

1.  Lipomata  (fatty  tumours). 

2.  Chondromata  (cartilage  tumours). 

3.  Osteomata  (osseous  tumours). 

4.  Odontomata  (tooth  tumours). 

5.  Fibromata  (fibrous  tumours). 

6.  Myxomata. 

7.  Gliomata  (neuroglia  tumours). 

8.  Sarcomata. 

9.  Myomata  (muscle  tumours). 

10.  Neuromata  (tumours  on  nerves). 

11.  Angeiomata  (tumours  composed  of  blood-vessels). 

12.  Lymphangeiomata  (tumours  of  lymphatic  vessels). 

LIPOMATA    (fatty    TUMOURS). 

A  Lipoma  is  a  tumour  composed  of  fat.  The  various 
species  of  this  genus,  determined  mainly  by  the  situations  in 
which  they  arise,  are  :  1,  Subcutaneous  ;  2,  subserous  ;  3,  sub- 
synovial ;  4,  submucous  ;  5,  intermuscular ;  6,  intramuscular  ; 
7,  parosteal ;  8,  meningeal. 

1.  Subcutaneous  Lipomata. — Beneath  the  skin  there  exists 
a  layer  of  fat,  which  varies  in  thickness  in  different  parts,  but 
is  most  abundant  over  the  trunk  and  trunk  ends  of  the  limbs. 
This  subcutaneous  fat  is  a  common  situation  in  which  to  find 
lipomata.  Usually  they  occur  as  irregularly  lobulated  encap- 
suled  tumours,  more  or  less  adherent  to  the  skin.  Unless  they 
have  been  irritated,  lipomata  are  movable  within  their  cap- 
sules. Generally  one  lipoma  is  present,  but  two,  ten,  twenty, 
or  more  may  occur  concurrently  on  the  same  individual.  In 
size  they  vary  widely ;  a  lipoma  weighing  sixteen  ounces  is  a 
tumour  of  fair  size  ;  exceptional  specimens  have  been  reported 
to  weigh  fifty,  eighty,  and  even  one  hundred  pounds.  Although 
subcutaneous  lipomata  are  for  the  most  part  confined  to  the 
trunk  and  trunk  ends  of  limbs,  they  ]nay  arise  on  the  distal 


4  CONNI<:CTIVI<:   TISSUE   TUMOURS. 

parts  of  tlio  limbs,  such  as  the  hands  and  feet.  Many  speci- 
mens have  been  observed  in  the  pahii  of  the  hand  (Fig.  1),  a 
situation  in  which  they  are  apt  to  give  rise  to  difficulty  in 
diagnosis,  more  especially  as  they  simulate  compound  ganglia 
of  the  flexor  tendons.  The  lobes  of  fat  are  apt  to  burrow 
beneath  the  palmar  fascia,  and  it  is  probable  that  some  lipo- 
mata  of  the  palm  originate  beneath  this  fascia,  in  the  lobules 


Fig.  1. — Lipoma  in  tlie  palm  of  the  hand. 

of  fat  lying  between  the  lumbricales.  Fatty  tumours  are 
occasionally  found  on  the  fingers  :  Steinheil*  has  collected  a 
large  number  of  examples.  A  lipoma  in  the  sole  of  the  foot 
is  more  comprehensible  than  one  in  the  palm  of  the  hand,  yet, 
strange  to  relate,  they  are  far  more  frequent  in  the  hand  than 
in  the  foot ;  in  both  situations  they  are  apt  to  be  congenitaLf 

*  Bruns,  Beitriige,  bd.  vii.  605. 

t  Gay,  Trans.  Path.  Soc,  vol.  xiv.  243,  and  Lockwood,  ibid.,  vol,  xxxvii.  450. 


LIFOMATA.  5 

Subcutaneous  lipomata  are  often  symmetrical  (Fig.  2)  and 
are  apt  to  become  pedunculated,  especially  when  growing  from 
the  thigh.  Pedunculated  lipomata  are  never  very  large,  and 
when  the  pedicle  is  thin  it  will  become  twisted  by  the  rotatory 
movements  of  the  tumour,  the  growth  of  which  will  in  con- 
sequence be  arrested,  or  at  least  checked. 

Fatty  tumours  are  rarely  met  with  upon  the  head  or  face. 


Fig.  2. — Lipoma  of  the  left  axilia;  a  similar  tumour  occupied  the  liglit  axilla. 

but  I  have  on  three  occasions  removed  a  lipoma  from  beneath 
the  skin  covering  the  temporal  fascia :  the  largest  specimen  is 
depicted  in  Fig.  3. 

There  is  a  variety  known  as  the  diffuse  lipoma ;  in  typical 
cases  the  tumours  appear  as  symmetrical  swellings  in  the  neck 
and  on  each  side  of  the  ligamentum  nuchse.  The  fat  has  a 
coarsely  granular  appearance,  due  to  being  bound  ujj  in  tiny 
lobules,  which  causes  it  to  resemble  omentum.  In  the  neck 
these  collections  of  fat  are  situated  on  the  deep  as  well  as  the 
superficial  aspect  of  the  platysma  muscle.  Similar  unencap- 
suled  masses  of  fat  occur  in  the  groin,  pubic  region,  and  axillae 
of  those  who  are  unfortunate  enough  to  possess  them  in  the 
neck  (Fig.  4). 


6  CONNECTIVE   TISSUE   TUMOURS. 

There  is  a  variety  of  fatty  tiiiiiour  sometimes  called,  on 
account  of  its  vascularity,  ncjevo-lvporaa  ;  some  are  of  opinion 
that  it  is  a  nieviis  which  has  undergone  fatty  degeneration. 
Possibly  some  of  the  vascular  lipomata  met  with  on  the  face 
have  this  origin. 

2,  Subserous  Lipomata. — The  peritoneum,  like  the  skin, 
rests  upon  a  bed  of  fat,  the  thickness  of  which  varies  consider- 
ably.     As  in  the  case  of  subcutaneous  lipomata,  those  which 


Fig.  3. — Lipoma  superficial  to  tlie  temporal  fascia. 

occur  in  the  subserous  tissue  may  be  sessile,  pedunculated,  or 
diffuse. 

Surgeons  have  long  been  aware,  in  oj)erating  for  inguinal 
or  femoral  hernia,  that  occasionally  they  come  across  a  mass 
of  fat,  and  find  difficulty  in  determining  whether  it  be  omental 
or  a  local  increase  of  the  subserous  fat  surrounding  the  hernial 
sac.  It  is  now  clear  that  in  the  neighbourhood  of  the  femoral 
and  inguinal  canals  an  overgrowth  of  the  subserous  fat  may 
occur  and  be  mistaken  for  a  hernia,  and  individuals  have  been 
recommended  to  wear,  and  have  actually  worn,  trusses  for 
fatty  tumours  of  this  character.      It  is  also  clear  that  as  these 


LIPOMATA.  7 

local  overgrowths  of  fat  arise  and  protrude  in  the  groin,  they 
occasionally  draw  with  them  a  pouch  of  peritoneum  unasso- 
ciated  with  a  hernia.  These  pouches  may  afterwards  lodge 
a  piece  of  gut,  and  become  true  hernial  sacs.  Thus  peritoneal 
pouches,  produced  mechanically  by  subserous  lipomata,  may 
subsequently  become  hernial  sacs  :  on  the  other  hand,  lipomata 
may  arise  in   relation  with  peritoneal   pouches   which   were 


Fig.  4. — Diffuse  lipoma  of  tlie  neck.     (After  Morrant  Baker.) 

originally  hernial  sacs.  In  some  cases  a  subserous  lipoma  of 
this  character  will  invaginate  a  peritoneal  pouch  and  form  a 
pedunculated  tumour  within  the  hernial  sac.  Fatty  tumours 
sometimes  arise  in  the  scrotum^or  labium  without  being 
connected  with  hernial  pouches.* 

Lipomata  arising  in  the  subperitoneal  tissue  occasionally 
appear  in  the  anterior  abdominal  wall,  especially  near  the  um- 
bilicus ;  they  are  sometimes  referred  to  as  "  fatty  hernise  of  the 

*  J.   Hutchinson,  jun.,   Trans.  Path.  Soc,   vol.  xxxvii.  451  and  vol.  xxxix., 
gives  a  good  account  of  hernial  lipomata. 


8  CONNECTIVE    TISSUE    TUMOURH. 

linea  alba,"  and  arc  frequently  associated  with  peritoneal 
pouches.  These  lipomata  siniulate  hernia:;  still  further  when 
the  traction  they  exercise  on  the  peritoneum  causes  pain. 
Subserous  lipomata  on  the  under  surface  of  the  diaphragm 
may  pass  upwards  into  the  mediastinum  through  the  space 
which  exists  behind  the  ensiform  cartilage. 

A  few  cases  are  known  in  which  lipomata  have  grown  be- 
tween the  layers  of  the  broad  ligament ;  *  in  one  case  the 
tumour  was  so  large  as  to  simulate  an  ovarian  tumour. f 

Enormous  subserous  lipomata,  in  many  respects  resembling 
the  diffuse  tumours  of  the  subcutaneous  tissue,  have  been 
described.  Pick|  recorded  a  case  in  which  a  mass  of  fat 
weighing  thirty  pounds  was  found  posterior  to  the  transverse 
colon.  Meredith  §  successfully  removed  an  omental  lipoma 
weighing  fifteen  pounds  and  a  half  from  a  woman  sixty-two 
years  old ;  the  operation  was  undertaken  because  the  tumour 
was  thought  to  be  ovarian.  Cooper  Forster||  met  with  a 
similar  tumour,  weighing  fifty-three  pounds,  in  a  woman 
sixty-three  years  old. 

Hernial  lipomata  are  interesting,  for  they  explain  the  mode 
in  which  appendices  epiploicas  arise :  they  are  localised 
pedunculated  overgrowths  of  subserous  fat,  and  are  particu- 
larly large  and  arborescent  in  the  neighbourhood  of  an  old 
syphilitic  stricture  of  the  rectum. 

In  well-nourished  individuals  the  fat  of  the  appendices 
epiploicse  is  directly  continuous  with  the  fat  in  the  layers  of 
the  mesentery ;  when  wasting  occurs  the  fat  between  the 
appendices  and  the  mesentery  is  liable  to  atrophy  and  leave 
an  adipose  nodule  at  the  bottom  of  a  peritoneal  pouch  (Fig.  5). 
The  movements  of  the  intestine  and  the  traction  of  the 
nodule  lead  to  the  formation  of  a  pedicle  which  often  becomes 
twisted ;  sometimes  the  pedicle  is  so  thin  that  it  breaks,  and 
the  appendix  is  set  free.  Pieces  of  fat,  not  infrequently  calci- 
fied, detached  in  this  way,  have  been  found  in  hernial  sacs. 

Pedunculated  lipomata  of  the  colon  are  not  uncommon  in 

*  Parono,  Ann.  dl  Ostet.  Milano,  1891,  xiii.  103,  pi.  1. 
t  Treves,  Trans.  Clin.  Soc,  vol.  xxvi. 
X  Trans.  Path.  Soc,  vol.  xx.  337. 
§  Trans.  Clin.  Soc,  vol.  xx.  206. 
II  Trans.  Patli.  Soc,  vol.  xix.  246. 


LIPOMATA.  ^ 

horses  and  oxen :  I  have  known  them  weigh  tw^o  pounds ;  they 
are  apt  to  cause  invagination  of  the  bowel. 

3.  Subsynovial  Lipomata. — Beneath  the  subserous  tissue 
of  large  joints,  such  as  the  knee,  there  is  a  layer  of  fat  of  varying 
thickness.  This  fat  may,  as  in  the  case  of  inguinal  lipomata, 
increase  m  quantity  and,  projecting  into  the  joint,  form  a  fatty 
tumour.  A  common  situation  for  this  to  occur  is  beside  the 
patella,  at  the  spot  normally  occupied  by  the  alar  ligaments. 


Fig.  5.— Small  pendulous  appendices  epiploica;,  with  twisted  pedicles, 
of  the  ascending  colon. 

Many  specimens  are  doubtless  due  to  overgrowth  of  the  fat  in 
the  alar  fringes,  but  they  may  arise  in  other  parts  of  the  joint. 
The  best  known  variety  of  subsynovial  fatty  tumour  is 
that  to  which  MllUer  ajjplied  the  term  "  lipoma  arborescens." 
This  condition  is  often,  but  by  no  means  always,  associated 
with  rheumatoid  arthritis.  A  typical  specimen  from  the 
shoulder-joint  is  represented  in  Fig.  6,  consisting  of  small 
linger-like  processes  of  fat  projecting  into  the  cavity  of  the 
joint ;  each  process  is  covered  by  synovial  membrane.  The 
lipoma  arborescens  bears  precisely  the  same  relation  to  the 
synovial  membrane  that  the  appendices  epiploicse  bear  to  the 
peritoneal  investment  of  the  colon  and  sigmoid  flexure. 


10 


CONNECTIVE   TISSUE    TUMOUnS. 


4.  Submucous  Lipomata. — Fat  exists  in  the  subimicous 
tissue  in  many  situations  and,  like  that  in  the  subcutaneous 
tissue,  is  not  infrequently  the  source  of  lipomata.  Thus 
Virchow*  has  figured  a  fatty  tumour  situated  Ijeneath  the 
mucous  membrane  of  the  stomach,  near  the  pylorus :  it  was  as 
big  as  a  nut.     They  also  grow  from  the  jejunum  and  hang  as 


Lipoma  arborescens  of  the  shoulder. 


pedunculated  tumours  in  the  gut,  and  have  caused  intussus- 
ception. 

Laryngeal  lipomata  are  rare.  One  of  the  most  remarkable 
examples  was  described  by  Holt.f  The  patient,  a  man. 
died  suddenly :  hanging  from  the  left  aryteno-epiglottic  fold 
and  from  the  side  of  the  epiglottis  was  a  pedunculated 
tumour,  which  extended  into  the  oesophagus  to  a  distance  of 


*  "  Krank.  Geschwiilste,"  bd.  i.  372. 
f  Trans.  Path.  Soc,  vol.  xxxii.  243. 


LIPOMATA.  '         11 

22'5  cm.  (9").  It  consisted  of  fat  covered  with  nmcoiis 
membrane. 

Sydney  Jones*  removed  a  lipoma  from  the  right  aryteno- 
epiglottic  fold  of  a  man  forty  years  old :  it  was  5  cm.  (2")  in 
diameter.  The  patient  could  protrude  the  tumour  into  his 
mouth.  Bruns  removed  a  lipoma  the  size  of  a  hazel  nut  from 
the  right  arytenoid  region. 

Subconjunctival  lipomata  occasionally  occur  near  the 
point  where  the  conjunctiva  is  reflected  from  the  lower  lid  to 
the  eyeball :  they  are  almost  confined  to  children.  Sometimes 
lipomata  arise  from  the  orbital  fat  and  project  the  conjunctiva 
in  the  neighbourhood  of  the  lachrymal  gland  and  near  the 
insertions  of  the  ocular  muscles. 

5.  Intermuscular  Lipomata. — Fatty  tumours  now  and 
then  arise  in  the  connective  tissue  between  muscles  :  they 
have  been  found  between  the  greater  and  lesser  pectorals, 
between  the  nmscles  of  the  tongue  and  the  intermuscular 
strata  of  the  anterior  abdominal  wall.  In  the  last-mentioned 
situation  they  have  been  known  to  attain  prodigious  pro- 
portions, f 

The  most  remarkable  variety  of  this  species  of  lipoma 
arises  in  connection  with  the  sucking-cushion.  This  curious 
ball  of  fat  is  situated  between  the  masseter  and  buccinator 
muscles,  and  comes  into  close  relation  with  the  buccal  mucous 
membrane.  It  is  believed  to  play  an  important  function  in 
connection  with  sucking,  by  distributing  atmospheric  pressure 
and  preventing  the  buccinators  from  being  forced  between  the 
alveolar  arches  when  a  vacuum  is  created  in  the  mouth.  They 
are  relatively  much  larger  in  infants  than  in  adults.  Ranke  J 
also  points  out  that  in  emaciated  children  the  cushions  are 
only  slightly  diminished  in  size  even  when  there  is  scarcely 
any  subcutaneous  fat.     (Figs.  7  and  8.) 

The  sucking-cushions  sometimes  enlarge  in  adults,  and 
simulate  more  serious  species  of  tumours,  and  it  is  curious 
that  in  some  of  the  recorded  cases  the  enlargement  of  the 
cushion  has  been  associated  with  the  impaction  of  a  salivary 

*  Trans.  Path.  Soc,  vol.  v.  123. 

f  Sir  Astley  Cooper,  Medico-Chir.   Trans.,  vol.  xi.  440.     Eve,  Trans.  Path. 
Soc,  vol.  xxxix.  29.5.    Abdel-Fattah  Fehmy,  Brit.  Med.  Journal,  1893,  vol.  i.  459. 
X  Virchow's  "  Archiv,"  bd.  xcvii.  527. 


12 


CONNECTIVE   TISSUE   TU}fC)TjnS. 


Fig.  7.— Enlarged  sucking-eusbion.    {After  Raiilcc.) 

calculus  in  the  duct  of  the  parotid  gland.*    The  association  of 
an  impacted  salivary  calculus  and  an  enlarged  sucking-cushion 


Fig.  S.— Emaciated  cliild  crying  and  displaying  tlie  sucking-cushions.     {After  PuinU.) 

*  Berger,    Gaz.    des   Eopitaux,   Nov.    15,    1883;  and   Owen,    Lancet,    1890, 
vol.  ii.  71. 


LI  POM  AT  A. 


13 


is  interesting  in  relation  with  an  observation  of  Norman  Moore, 
who  found  a  large  collection  of  fat  around  a  ureter  at  the  site 
of  an  impacted  calculus.  (Museum,  Royal  College  of 
Surgeons,  196a.) 

t).  Intramuscular  Lipomata. — Many  examples  of  fatty 
tumours  occurring  in  the  midst  of  muscles  have  been  reported, 
and  are  of  interest  from  the  trouble  they  cause  in  diagnosis. 
They  have  been  found  in  the  deltoid,  biceps  humeri,  com- 
plexus,  and  rectus  abdominis ;  in  the  muscular  tissue  of  the 
heart,  and  in  the  middle  of  a  submucous  myoma  of  the 
uterus.* 

7.  Parosteal  Lipomata. — ^This  term  has  been  applied  to 
fatty  tumours  arising  from  the  periosteum  of  bone.  They  are 
usually  congenital,  and  nearly  always  contain  tracts  of  striated 
muscle  fibre.  Some  of  these  tumours  are  clinical  puzzles. 
Dr.  F.  Taylorf  reported  a  case  in  which  a  fatty  tumour  grew 
from  the  anterior  surface  of  the  bodies  of  the  cervical  vertebra3 ; 
it  projected  the  posterior  wall  of  the  pharynx,  and  sinudated 
a  post-pharyngeal  abscess.  The  patient  was  a  girl  four  years 
old.  I  have  removed  parosteal  lipomata  from  the  dorsal 
surface  of  the  infra-spinous  fossa  of  the  scapula,  the  body 
of  the  pubes,  and  the  frontal  bone  immediately  above  the 
right  superciliary  ridge. 

The  appended  table  contains  references  to  descriptions  and 
accessible  examples  of  parosteal  lipomata. 


PAROSTEAL    LIPOMATA. 


Seat. 

Reporter. 

Reference. 

Femur    . 

D'Arcy  Power 

Trans.  Fath.  Soc,  xxxix.  270. 

Tibia  and  Fibula    . 

Butlin     . 

Traits.  Path.  Soc,  xxviii.  221. 

Ischium 

T.  Smith 

Trans.  Path.  Soc,  xvii.  286. 

Spine  of  Ilium 

Walsham  . 

Trans.  Path.  Soc,  xxxi.  310. 

Clavicle . 

Gould  . 

Museum,  Middlesex  Hospital. 

Scapula  . 

T.  W.  Nunn  . 

Museum,  Middlesex  Hospital. 

Neck  of  Radius 

T.  Smith 

Trans.  Fath.  Soc,  xix.  344. 

Coccyx  . 

T.  Smith 

Trans.  Path.  Soc,  xxi.  334. 

Frontal  . 

Sydney  Jones 

Trans.  Fath.  Soc,  xxxii.  243. 

*  T.   Smith,  Trans.  Path.   Soc,  vol.  xii.    148.      See  also   Lebert, 
d" Anatomic  Pathologique,"  plate  xvi.,  fig.  11,  t.  i.  p.  128. 
t  Trans.  Path.  Soc,  vol.  xxviii.  216. 


■  Traite 


14 


CONNECTIVE    TISSUE    TUMOURS. 


8.  Meningeal  Lipomata. — Fatty  tumours  occur  within  the 
spinal  dura  niator,  as  well  as  external  to  this  membrane.  When 
growing  within  the  sheath  they  surround  the  cord.  Gowers,* 
Recklinghausen,t  and  Obre:j:  have  recorded  examples.  In 
the  cases   described  by  the  first  two  observers  the  tumours 


Fig.  9. — Meningeal  lipoma  simulating  a  spina  bifida  in  a  child  eight  months  old, 
(After  Timoiii.i) 

contained  striped  muscle  tissue.  The  occurrence  of  an  intra- 
dural lipoma  is  not  surprising,  as  the  loose  connective  tissue 
between  the  cord  and  dura  mater  contains  fat. 

Fatty  tumours  are  not  uncommon  in  the  middle  line  of  the 

*  Trans.  Path.  Soc,  vol.  xxvii.  19. 

t  Virchow's  "  Archiv,"  Tbd.  cv.  243. 

I  Trans.  Path.  Soc,  vol.  iii.  248. 

§  Arch.  Froviiiciales  de  Chirurr/ie,  1892,  p.  179. 


LIFOMATA. 


15 


back,  especially  in  the  liimbo-sacral  region,  overlying  the  sac 
of  a  spina  bifida.     (Figs.  9  and  10.) 

Clinical  Features. — Although  lipomata  occur  more  fre- 
quently than  any  other  genus  of  connective  tissue  tumours, 
and  may,  in  most  instances,  be  diagnosed  with  absolute  cer- 
tainty, yet  under  sonae  conditions  they  are  very  puzzling,  and 
give  rise  to  much  difference  of  opinion.  The  subcutaneous 
species    is   rarely   the   source   of  doubtful   diagnosis,   unless 


Fig.  10.— Meningeal  lipoma  overlying  the  sac  of  a  spina  bifida. 
{Museum,  Roycd  College  of  Surgeons.) 

situated  in  the  palm  of  the  hand,  sole  of  the  foot,  or  on  the 
scalp.  The  intimate  relation  between  the  tumour  and  the  over- 
lying skin,  the  absence  of  definite  boundaries  and  its  dough- 
like consistence,  are  usually  sufficiently  trustworthy  guides. 
When  a  lipoma  is  connected  with  the  periosteum  of  a  long 
bone  it  will  sometimes  simulate  a  sarcoma  ;  when  embedded 
in  a  muscle  the  most  divergent  opinions  are  often  expressed 
in  regard  to  the  nature  of  the  tumour. 


16  CONNECT fVE    TISSUE    TUMOURS. 

Ilcfei'cnce  lias  already  been  niado  to  those  large  lipoiriata 
which  arise  in  the  siiljperitoneal  tissue  and  the  way  they 
mimic  the  signs  of  ovarian  tumours.  Lipomata  in  the  neigh- 
bourhood of  hernial  openings  have  often  been  confounded  with 
herniie. 

Especial  attention  must  be  drawn  to  supposed  fatty 
tumours  situated  in  the  middle  line  of  the  back :  in  most  cases 
these  are  abnormal  masses  of  fat  overlying  the  sacs  of  spinse 
bifidfe.  Incautious  surgeons,  in  operating  upon  such  tumours, 
have  unexpectedly  opened  the  dura  mater. 

Treatment. — Solitary  subcutaneous  lipomata  should,  as  a 
general  rule,  be  removed.  When  very  many  tumours  are 
present  (ten  or  twenty)  it  is  not  customary  to  interfere  with 
them,  for  when  multijDle  they  rarely  attain  uncomfortable  or 
dangerous  proportions.  It  occasionally  happens  with  multiple, 
(and  also  with  solitary)  lipomata,  that  one  or  other  becomes 
irritated  with  some  part  of  the  dress,  such  as  petticoat  bands, 
braces,  etc.,  or  in  some  jDarticular  employment  followed  by  the 
individual.     Such  tumours  should  invariably  be  removed. 

The  removal  of  a  subcutaneous  lipoma  is  one  of  the 
simplest  proceedings  in  surgery,  but  the  extirpation  of  a  large 
subperitoneal  fatty  tumour  is  often  attended  with  difficulty 
and  grave  danger.* 

Diffuse  lipomata  do  not  admit  of  removal.  It  was  for- 
merly stated  that  liquor  potass^,  taken  internally,  caused 
them  to  diminish  in  size  and  even  disappear.  So  far  as  my 
observations  have  extended,  the  administration  of  this  drug 
is  useless  in  preventing  the  growth  or  reducing  the  size  of 
these  tumours. 

*  Homans,   International   J.   Med.  ScL,  April,    1891 ;    and   Spencer   "Wells, 
"  Ovarian  and  Uterine  Tumours,"  1882. 


CHAPTER     11. 

CHONDROMATA    (CARTILAGE    TUMOURS). 

Chondromata  (enchondromata)  are  tumours  composed  of 
hyaline  cartilage.  Tliis  genus  contains  three  species : — 1, 
chondromata  ;  2,  ecchondroses  ;  3,  loose  cartilages  in  joints. 

1.  Chondromata. — Cartilage  tumours  in  their  typical  con- 
dition occur  in  long  bones,  and,  as  a  rule,  grow  in  relation  with 
the  epiphysial  cartilages,  hence  they  are  most  frequently 
observed  in  children  and  young  adults.  Often  a  chondroma 
is  solitary,  but  very  frequently  many  exist,  especially  on 
the  long  bones  of  the  hand.  A  remarkable  case  is  de- 
picted in  Fig.  11 ;  this  patient  was  under  observation  at  the 
Tubingen  Clinic  twenty-five  years.  He  died  at  the  age  of 
fortj^-five.  Most  of  the  long  bones  of  the  limbs  were  occupied 
with  cartilage  tumours.  Some  of  them  were  very  large.'^ 
Kast  and  Recklinghausenf  have  described  a  similar  case,  and 
I  have  a  photograph  of  a  lad  who  used  to  be  exhibited  for 
gain  at  fairs  in  various  parts  of  England,  with  cartilage 
tumours  on  his  hands,  feet,  and  legs  as  numerous  as  in 
Steudel's  unfortunate  patient. 

Chondromata  are  always  encapsuled,  and  form  deep 
hollows  in  the  bones  from  which  they  grow ;  they  are  painless, 
grow  slowly,  and  are  firm  to  the  touch.  Frequently  they 
undergo  mucoid  softening,  then  the  softened  patches  give 
rise  to  fluctuation.  This  often  serves  to  distinguish  them 
from  osteomata,  with  which  they  are  liable  to  be  confounded 
clinically.     Cartilage  tumours  are  prone  to  ossify. 

The  frequency  of  chondromata  in  those  who  were  rickety 
in  early  life  may  be  due,  as  Virchow  pointed  out,  to  the 
existence  of  untransformed  pieces  of  cartilages  acting  the  part 
of  tumour-germs.  Such  remnants  of  unossilied  cartilage 
(cartilage  islands)  are  not  difficult  of  demonstration  in  rickety 
bones.     (Fig.  12.) 

It  is  a  curious  circumstance  that  the  tissue  of  a  chondroma 

*  Bruns,  Beitrage,  bcl.  viii.  503. 

t  Virchow's  "Archiv,"  bd.  cxviii.  s.  i. 


IS 


CONNEC'TIVI'J    TL^HUE    TUMOURS. 


resembles,   histologically,    the   bluish    translucent   epiphysial 
cartilage  characteristic  of  progressive  rickets. 

2.  Ecchondroses  may  be  defined  as  small  local  overgrowths 
They  are  best  studied  in  three  situations — viz., 


of  cartilages 


Fig.  11. — Lad  twenty  years  of  age  -with  multiple  cliondromata.     (After  SteudeJ.) 

along  the  edges  of  articular  cartilages,  the  laryngeal  cartilages, 
and  the  triangular  cartilage  of  the  nose. 

Ecchondroses  of  articular  cartilage  are  especially  common 
in  the  knee  joint,  and  occur  in  connection  with  the  condition 
known  as  rheumatoid  arthritis.  They  are  frequent  in  the 
joints  of  persons  past  the  meridian  of  life,  and  they  present 


CHONDBOMATA.  19 

themselves  as  small  projecting  prominences  along  the  margins 
of  the  articular  cartilage.  Often  the  edge  of  the  cartilage  is 
produced  into  a  raised  prominent  lip,  the  regularity  of  which 
is  broken  here  and  there  by  a  sessile  or  pedunculated  nodule. 
When  these  nodules  are  examined  many  of  them  present 
on  their  outer  surface  a  convex  outline,  but  on  the  inner 
aspect — that  looking  towards  the  joint — they  are  concave,  the 
concavity  being  produced  by  friction  during  the  movements  of 
the  joint,  or  by  pressure  when  the  parts  are  at  rest.  Occa- 
sionally erosion  of  the  ecchondrosis  may  extend  so  deeply  that 
by  some  extra  movement  of  the  joint  the  pedicle  is  broken, 
and  the  detached  nodule  either  falls  as  a  loose  body  into  the 


Fig.  12.— Condyles  and  epiphysial  line  of  a  rickety  feniur,  witli  a  cartilage  Lsland. 

joint-cavity,  or  it  may  be  retained  in  position  by  its  attachments 
to  the  fibrous  structures  of  the  articulation. 

Laryngeal  ecchondroses  are  by  no  means  common ;  they 
grow  from  the  thyroid,  cricoid,  and  occasionally  the  arytenoid 
cartilages.  Paul  Bruns*  collected  fourteen  cases  of  laryngeal 
chondromata ;  of  these,  eight  sprang  from  the  cricoid,  four 
from  the  thyroid,  one  from  the  arytenoid,  and  one  from  the 
epiglottis.  Most  of  the  ecchondroses  of  the  cricoid  cartilage 
sprang  from  the  broad  posterior  plate.  In  many  of  the 
cases  the  inner  and  outer  surfaces  of  the  cricoid  were  involved, 
so  that  the  tumour  encroached  upon  the  cavity  of  the 
larynx.  Ecchondroses  vary  greatly  in  size  ;  some  are  scarcely 
larger  than  a  pea,  others  may  be  as  big  as  walnuts.      Morell 

*  Beitrcige  zu  Klin.-Chir.,  bd.  iii.  347. 


20  aONNKGTIVK   TfSHUE    TUMOURS. 

Mackenzie*  has  described  an  example  growing  from  the  cricoid 
which  attained  the  size  of  a  bantam's  Qg^ ;  in  this  instance  the 
tumour  extended  downwards  in  front  of  the  trachea.  Small 
ecchondroses  growing  from  the  inner  surfaces  of  the  laryngeal 
cartilages  are  more  dangerous  than  the  larger  examples 
springing  from  their  outer  surfaces.  Ecchondroses,  when  pro- 
jecting into  the  larynx,  are  covered  with  its  mucous  mem- 
brane ;  they  may  be  smooth  or  tuberculatecl,  round  or  conical. 
In  exceptional  cases  the  overlying  mucous  membrane  has  been 
found  ulcerated.  Chondromata,  wdien  they  project  into  the 
larynx,  produce  stridor,  difficulty  in  breathing,  and  sometimes 
interfere  with  the  movements  of  the  vocal  cords.  When  the 
tumours  only  involve  the  outer  surfaces  of  the  laryngeal  carti- 
lages, they  do  not  as  a  rule  produce  any  inconvenience  unless 
they  are  exceptionally  large. 

Small  outgrowths  from  the  triangular  cartilage  of  the 
nose  are  by  no  means  uncommon ;  they  never  attain  a  large 
size,  and  are  always  sessile.  It  is  difficult  to  imagine  that 
ecchondroses  of  the  nasal  cartilage  could  be  a  source  of  ]nuch 
inconvenience,  but  some  surgeons,  who  are  enthusiastic  in 
treating  diseases  of  the  nasal  passages,  view  them  with  dis- 
favour. 

3.  Loose  Cartilages. — Bodies  of  various  kinds  are  found 
loose  in  the  cavities  of  large  joints,  but  those  to  be  considered 
under  the  head  of  chondromata,  in  addition  to  detached 
ecchondroses,  are  pieces  of  hyahne  cartilage  found  hanging  in 
the  joint  by  narrow  pedicles,  or  occupying  depressions  in  the 
bone,  from  which  they  are  occasionally  dislodged.  Structurally 
they  are  composed  of  hyaline  cartilage,  and  assume  various 
forms.  Some  appear  as  flat  discs,  others  are  ovoid;  they 
may  be  perfectly  smooth,  or  present  an  irregular  worm-eaten 
appearance,  and  the  majority  are  impregnated  with  calcareous 
particles.  It  is  a  remarkable  fact  that  in  many  instances  in 
which  a  loose  cartilage  has  been  found  in  one  joint,  a  body 
identical  in  size  and  shape  has  been  found  in  the  corresponding 
joint  of  the  opposite  limb.f     Loose  cartilages  may  be  single  or 

*  Trans.  Path.  Soc,  vol.  xxi.  58. 

t  Bowlby,  Trans.  Path.  Soc,  vol.  xxxix.  281 ;  Glutton,  ihid.,  vol.  xxxix.  284 ; 
American  Journal  of  Med.  Sci.,  vol.  i.  303  ;  Weichselbaum,  Virchow's  "  Archiv," 
Ivii.  127. 


GHONDROMATA.  21 

multiple  :  several  liiindred  may  exist  in  one  joint,  and  vary 
in  size  from  a  rape-seed  to  an  almond. 

The  origin  of  these  cartilages  is  interesting.  In  large 
joints,  such  as  the  hip,  knee,  or  shoulder,  it  is  easy  to  demon- 
strate, in  the  recesses  of  the  joint  near  the  spot  where  the 
synovial  membrane  becomes  continuous  with  the  margin  of  the 
articular  cartilage,  villous-like  processes  of  the  synovial  mem- 
brane projecting  into  the  joint.  Under  certain  conditions, 
especially  that  known  as  rheumatoid  arthritis,  these  villi 
become  greatly  enlarged  and  increase  in  number  until  the 
whole  synovial  membrane  may  be  so  covered  with  them  as  to 
become  quite  velvety  in  appearance.  Structurally,  these 
synovial  villi  consist  of  a  reduplication  of  the  serous  mem- 
brane, and  contain  tufts  of  capillaries.  As  they  enlarge,  some 
of  them  undergo  chondrification,  and  this  change  may  take 
place  so  extensively  that  a  villous  process  is  entirely  con- 
verted into  hyaline  cartilage,  which  becomes  the  matrix  for 
a  deposit  of  lime  salts.  As  these  nodules  of  cartilage  are 
merely  sustained  by  narrow  pedicles,  the  nodules  may  be  de- 
tached either  by  their  mere  weight,  undue  movement  of  the 
joint,  or  from  axial  rotation,  and  tumbling  into  the  joint  give 
rise  to  all  the  inconveniences  characteristic  of  a  loose  body. 
Specimens  occasionally  come  to  hand  in  which  cartilaginous 
bodies  of  this  description  may  be  found  sessile  among  the 
fringes,  or  hanging  on  good  pedicles,  or  with  stalks  so  thin 
that  they  appear  to  be  on  the  eve  of  detachment. 

Occasionally  these  overgrown  synovial  villi,  instead  of  chon- 
drifying,  are  converted  into  oval  bodies,  which,  on  microscopic 
examination,  present  a  central  cavity  surrounded  by  a  lami- 
nated structureless  substance.  To  the  naked  eye  many  of  these 
oval  bodies  resemble  cartilage,  and  it  is  only  on  microscopi- 
cal examination  that  it  is  possible  to  distinguish  between 
them ;  many  are  infiltrated  with  calcareous  granules.  These 
oval  bodies  are  present  in  some  cases  in  great  number.  On 
one  occasion  Mr.  Bentlif  sent  me  1,532  which  he  removed 
from  the  shoulder  joint  of  a  girl.  Loose  bodies  of  this 
character  occur  not  only  in  joints,  but  in  compound  ganglia 
and  in  bursse. 

In  concluding  this  account  of  cartilage  tumours  it  is  very 
necessary  to  point  out  that  every  tumour  containing  cartilage 


22  CONNECTIVE   TLSSUE   TUMOURS. 

is  not  necessarily  a  chondroma.  In  describing  sarcomata  it 
will  be  pointed  out  that  the  spindle-celled  species  is  very  apt 
to  contain  cartilage,  particularly  when  arising  in  the  testis, 
parotid  gland,  or  periosteum.  Much  ingenious  speculation 
has  been  exercised  to  account  for  the  presence  of  cartilage 
in  sarcomata  arising  in  such  structures,  but  it  appears  to  be 
an  extremely  easy  task  for  connective  tissue  to  form  hyaline 
cartilage. 

Treatment. — The  operative  treatment  of  chondromata  has 
been  greatly  simplified  since  surgeons  have  appreciated  the 
fact  that  these  tumours,  when  g'rowino'  in  relation  with  bones, 
are  distinctly  encapsuled.  Hence,  when  it  is  necessary  to 
interfere  with  a  chondroma,  even  in  cases  where  several 
tumours  are  present,  it  has  become  customary  to  incise  the 
capsule  and  shell  out  the  cartilage.  In  most  instances  this 
simple  method  is  successful.  Exceptionally,  however,  cases 
come  under  observation  which  demand  more  serious  measures. 
When  the  cartilage  tumours  are  very  numerous  on  the  bones 
of  the  hand,  the  fingers  are  so  crippled  and  useless  that 
amputation  becomes  necessary.  In  the  patient  represented 
in  Fig.  11  the  weight  of  the  tumours  caused  so  much  fatigue 
that  it  was  deemed  advisable  to  amputate  the  hand.  For- 
tunatel}^,  such  severe  treatment  is  very  rarely  needed. 

In  the  case  of  loose  bodies  in  joints  it  is  the  usual  practice, 
when  the  pieces  of  cartilage  are  in  the  habit  of  getting  between 
the  opposed  surfaces  of  the  joints,  to  open  the  synovial  cavity, 
and  remove  the  loose  body  or  bodies.  When  this  manoeuvre 
is  conducted  with  proper  care  it  is  highly  successful.  When 
the  loose  body  is  lodged  in  a  sacculus,  it  is  in  a  measure 
isolated  from  the  general  cavity  of  the  joint,  and  does  not  call 
for  interference.  The  smaller  bodies,  which,  like  mice,  slip  in 
and  out  of  the  recesses  of  a  complex  joint,  are  more  likely  to 
give  trouble  than  those  larger  pieces  of  cartilage,  sometimes  as 
big  as  chestnuts,  which  the  patients  can  grasp  with  their  fingers, 
and  slip  in  and  out  of  the  great  cul-de-sac  above  the  patella 
almost  as  readily  as  a  marble  may  be  manipulated  under  a 
tablecloth.     Bodies  of  this  sort  rarely  call  for  interference. 


23 


CHAPTER     III. 

OSTEOMATA    (OSSEOUS    TUMOURS). 

It  has  been  customary  to  describe  almost  all  Ivincls  of  tumours 
composed  of  bone,  or  bone-like  tissue,  under  the  name  of  exos- 
toses. A  critical  examination  of  these  tumours  indicates  that 
they  belong  to  at  least  two  genera,  osteomata  and  odontomata. 
The  term  exostosis  should  be  limited  to  irregular  bony  out- 
growths to  which  the  term  tumour  is  not  in  any  sense 
applicable. 

Osteomata  may  be  defined  as  ossitying  chondromata,  for 
they  are  found  near  the  epiphysial  lines  of  long  bones,  and 
when  they  arise  in  connection  with  flat  bones  it  is  generally  in 
the  vicinity  of  a  tract  of  cartilage.  Every  growing  osteoma 
has  a  cap  of  hyaline  cartilage,  which  stands  in  the  same 
relation  to  the  growth  of  the  tumour  as  an  epiphysial  line  to 
the  increase  in  lenofth  of  a  lon<y  bone. 

The  genus  osteoma  contains  two  species  : — 1,  the  compact 
or  ivory  osteoma ;  2,  the  cancellous  osteoma. 

1.  Compact  Osteomata. — These  are  structurally  identical 
with  the  tissue  forming  the  shaft  of  a  long  bone.  They  may 
■occur  on  any  part  of  the  skeleton,  but  are  more  frequent  in  the 
frontal  sinus,  external  auditory  meatus,  and  mastoid  process 
than  elsewhere. 

The  general  characters  of  an  osteoma  of  the  frontal  sinus 
may  be  gathered  from  the  specimen  (Figs.  13  and  14)  pre- 
served in  the  museum  of  the  Royal  College  of  Surgeons, 
London  ;  it  is  figured  in  Baillie's  "Morbid  Anatomy,"  fas.  x., 
pi.  i.,  fig.  2.  Unfortunately,  no  history  of  the  case  is  forth- 
coming. Many  of  these  tumours  extend  into  the  orbit,  and 
others  sometimes  make  their  way  through  the  posterior  part 
of  the  orbital  roof  into  the  cranial  cavity. 

Osteomata  of  this  kind  arise  occasionally  in  the  frontal 
sinuses  of  oxen,  and  form  huge  irregular  lobulated  masses, 
sometimes  weighing  as  much  as  sixteen  pounds,  and  as  dense 
as  ivory.  Similar  tumours  grow  from  the  petrosal  and  en- 
croach upon  the  cranial  cavity;  some  of  these  have  been 
reported  in  veterinary  literature  as  ossified  brains  ! 


24 


CONNECrrVE   T IS  HUE   TUMOURS. 


In  many  instances  very  large  tumours  have  been  removed 
from  the  maxillae  and  described  as  exostoses  ;  some  of  these 
were  huge  odontomes.     (See  next  Chap.) 


Fig.  13.— Osteoma  of  the  left  frontal  sinus  (anterior  view). 

Osteomata  at  the  margins  of  the  external  auditory  meatus 
have  been  especially  studied  because  they  are  apt  to  obstruct 


Fig.  14.— Osteoma   of  tlie   left   frontal   sinus,   seen   from   below. 
{Uiiseum,  Royal  College  of  Surgeons.) 

the  meatus  and  cause  deafness ;  when  both  meatuses  are 
affected — and  this  is  not  rare — absolute  deafness  may  result.  It 
is  a  curious  fact  that  osteomata  at  the  margins  of  the  auditory 
meatus  have  been  observed  in  many  different  races  of  men. 


OSTEOMATA.  25 

Professor  Sir  William  Turner*  has  drawn  attention  to  observa- 
tions of  Seligmann,  Welcker,  Barnard  Davis,  and  added  some 
of  his  own,  concerning  the  presence  of  such  exostoses  in 
certain  deformed  skulls  described  as  Titicaca's,  Huanaka's, 
and  Aymara's.  Also  in  skulls  from  the  Marquesas  Islands, 
Sandwich  Islands,  Chatham  Island,  and  New  Zealand.!  It  is 
not  surprising  that  osteomata  should  arise  from  the  walls  of 
the  external  auditory  meatus  when  we  remember  the  number 
of  centres  by  which  the  periotic  cartilage  is  transformed  into 
bone,  and  the  various  ossific  elements  that  come  into  relation 
with  each  other  at  this  meatus. 

2.  Cancellous  Osteomata. — These  tumours  in  structure  re- 
semble the  cancellous  tissue  of  bone,  and  are  soft  in  comparison 
with  the  preceding  species.  They  usually  possess  a  thick 
covering  of  hyaline  cartilage,  and  when  growing  at  the  distal 
end  of  the  radius,  or  tibia,  present  a  series  of  deep  channels 
for  the  passage  of  tendons.  Occasionally  an  osteoma  is 
pedunculated  ;  more  frequently  it  has  a  broad  base.  Osteo- 
mata, whether  sessile  or  stalked,  usually  grow  slowly,  but  in 
the  course  of  years  they  sometimes  attain  large  proportions. 
They  are  innocent  tumours,  but  occasionally  imperil  life 
by  mechanically  interfering  with  the  function  of  vital  organs. 
ReidJ  described  a  case  in  which  an  osteoma  grew  from  the 
posterior  surface  of  the  odontoid  process  and  projected  into 
the  neural  canal  to  the  extent  of  8  mm.  and  compressed  the 
spinal  cord  with  fatal  effect.  Although  in  themselves 
painless,  osteomata  often  induce  pain  by  pressing  on  nerve 
trunks  in  their  vicinity. 

Exostoses. — The  various  bony  outgrowths  classed  as 
exostoses  fall  into  three  groups  : — 

1.  Ossification  of  tendons  at  their  attachments. 

2.  The  sub-ungual  exostosis. 

3.  Calcification  of  inflammatory  exudations. 

1.  Exostoses  formed  by  Ossification  of  Tendons  at  their 
A  ttachments. 

The  long  bones  of  a  child  at  birth  are  smooth  in  outline 
and  almost  cjdindrical  in  shape  ;  the  periosteum  is  relatively 

*  Journal  of  An  at.  and  Fhysiologtj,  vol.  xiii.,  p.  200. 

t  Zoology  of  the  "  Challenger  Expedition,"  pt.  xxix.,  p.  117. 

+  Edin.  Med.  Joiirnal,  1843,  p.  194. 


26 


CONNECTIVE   TISSUE    TUMOUliS. 


thick,  and  gives  attachment  to  the  muscles.  On  examining  the 
long  bones  of  an  adult  muscular  man  their  shafts  are  found  to 
be  irregular,  and  present  many  asperities,  such  as  the  linea 
aspera,  gluteal  ridges,  oblique  lines,  and  the  like.  These 
ridges  and  lines,  in  the  majority  of  instances,  are  the  ossified 
insertions  of  muscles,  and  occasionally  they  are  so  pronounced 
as  to  be  appreciable  through  the  soft  structures,  and  are  then 
described   clinically   as   exostoses.     The   two   most   frequent 


Fig.  15. — Exostosis  of  the  femur :   its  surface  was  clad  witli  cartilage  and 
surmounted  by  a  bursa.     (After  Orlov:.*) 

examples  of  this  form  of  exostosis  are  the  adductor  tubercle 
of  the  femur  and  the  tubercle  on  the  tirst  rib  at  the  insertion 
of  the  scalenus  anticus.  Probably  the  most  common  exostosis 
is  that  which  occurs  in  the  tendon  of  insertion  of  the  adductor 
magnus  :  it  usually  assumes  the  form  of  a  broad  ledge  of  bone  ; 
exceptionally  it  is  stalked,  and  in  rare  cases  surmounted  by  a 
bursa  (Fig.  15);  the  walls  of  such  bursse  are  now  and  then 
furnished  with  villi,  and  even  loose  bodies  have  been  found 
in  them.    Care  must  be  taken  not  to  confound  a  supracondyloid 

*  Zeitschrift  fur  Chir.,  bd.  xxxi.  293. 


OSTEOMATA.  27 

process  of  the  humerus,  and  the  occasional  third  trochanter 
o±  the  femur,  with  exostoses. 

A  bursa  will  form  on  exostoses  or  osteomata  if  their  sur- 
faces be  exposed  to  pressure,  or  to  friction  from  the  movement 
of  tendons  and  muscles. 

Localised  outgrowths  are  very  common  on  the  facial  bones, 
especially  the  nasal  processes  of  the  maxillse,  where  they  may 
be  unilateral  or  bilateral.  (Fig.  16.)  The  cause  of  these  exos- 
toses is  obscure.  Small  irregular  osseous  prominences  are 
fairly  frequent  along  the  alveolar  borders  of  the  maxillas  and 
mandible. 


^Fig.  16. — Syiuiiietrical  exostoses  of  tlie  nasal  processes  of  the  maxilla-'.     {After  Hutchinson.*) 

Exostoses  of  the  maxilhe  similar  to  those  in  Fig.  16  have 
been  observed  in  natives  of  the  West  Coast  of  Africa.  In- 
teresting particulars  relating  to  these  cases  are  furnished  by 
Macalister,t  and  more  recently  by  Lamprey,:]:  of  the  Arni}^ 
Medical  Staff.  Macalister  discusses  the  condition  in  relation 
to  the  supposed  existence  of  horned  men  in  Africa. 

2.  The  Sub-wngital  Exostosis  is  a  troublesome  outgrowth 
from  the  ungual  phalanx  of  the  big  toe ;  it  makes  its  way  through 
the  bed  of  the  nail,  and  peers  out  between  the  nail  and  the 
skin  at  the  tip  of  the  toe,  nearer  the  inner  than  the  outer  side; 

*  "Illustrations  of  Clin.  Surgery,"  vol.  i.,  p.  2. 

t  Proc.  E.  Irish  Academy,  2nd  Series,  vol.  iii.,  1883. 

I  Brit.  Med.  Journal,  1887,  vol.  ii.,  1273. 


28 


(JONKEG  TI VE     TIHS  (TE     Tl  'MO  URS. 


its  appearance  is  so  characteristic  that  it  only  requires  to  he 
once  seen  to  be  appreciated  readily.     (Fig.  17.) 

The  sub-iingual  exostosis  is  never  very  large  :  as  a  rule,  it  is 
no  bigger  than  a  cherry-stone ;  exceptionally  it  may  be  double 
this  size,  but  larger  examples  are  excessively  rare.  The  soft 
tissue  overlying  the  exostosis  is  apt  to  ulcerate.  As  seen  pro- 
jecting beneath  the  nail  it  is  of  a  dull  red  colour.  When  the 
soft  tissues  investing  it  are  removed,  the  tumour  appears  as 
a  low  prominence  of  cancellous  bone  jutting  from  the  dorsal 
surface  of  the  terminal  phalanx.  These  outgrowths  are  prob- 
ably due  to  the  pressure  of  ill-fitting  boots,  and  should  be 
ranked  among  inflammatory  productions. 

3.  Exostoses  due  to  calcification  of 
injiammiatory  exudations  scarcely  re- 
quire consideration  in  this  work :  there 
is  reason  to  believe  that  some  of  the 
cases  described  as  multiple  exostoses, 
were  really  examples  of  the  strange  and 
rare  disease  known  as  "myositis  ossi- 
ficans." 

Bony  tumours  are  of  fairly  frequent 
occurrence  in  all  vertebrata.  Paul  Ger- 
vais*  has  published  descriptions  of  many 
interesting  specimens  from  fish.  Perhaps  the  most  striking 
example  is  furnished  by  the  skeleton  of  the  fish  Chmtodoii,  in 
which  some  of  the  bones  are  furnished  with  rounded  bony 
tumours.  The  museum  of  the  Royal  College  of  Surgeons  con- 
tains many  loose  bones  with  tumours,  as  well  as  the  skeleton 
of  the  original  fish  sent  by  William  Bellf  to  John  Hunter. 
(Fig.  18.)  Single  bones  of  CJuetodon  are  not  uncommon  in 
osteological  collections ;  Cuvier  explained  this  by  stating  that 
they  are  brought  home  by  travellers  who  have  eaten  this  fish. 
On  section  it  will  be  found  that  the  outline  of  the  ray  can  be 
clearly  defined  running  through  the  midst  of  the  tumour.  For 
fuller  details  relating  to  CJiietodon,  consult  the  subjoined 
reference.  :|: 

Treatment. — When   osseous   tumours   o-row   in  situations 


Fig.  17. — Big  toe  with  a 
sub-uiigual  e.xostosis. 


*  Journal  dc  Zoologic,  1875,  vol.  iv. 

t  Phil.  Trans.,  1793. 

X  Trans.  Path.  Soc,  vol.  xxx'x.  47! 


OSTEOMATA. 


29 


where  they  do  not  involve  important  structures,  the  rule  is  not  to 
interfere  with  them.    When  they  press  upon  nerves  and  occupy 


accessible  situations,  and  especially  when  pedunculated,  they 
may  be  removed  with  chisel  and  mallet,  or  with  stout  forceps. 


30  GONNEGTIVE    TISSUE   TUMOURS. 

Cranial  osteoiriata  are  as  a  rule  forinidablo  objects;  when 
growing  from  the  roof  of  an  orbit,  or  frontal  bone,  they  not 
infrequently  extend  as  deeply  into  the  cranial  cavity  as  they 
project  beyond  it.* 

Osteomata  obstructing  the  external  auditory  meatus,  and 
producing  deafness,  have  been  on  many  occasions  successfully 
perforated  by  means  of  steel  drills. 

Osseous  tumours,  especially  when  sessile  and  of  the 
ivory  variety,  sometimes  require  the  most  persevering  efforts 
of  the  surgeon,  aided  by  the  best  surgical  cutlery.  When 
exostoses  are  seated  near  joints  and  the  synovial  membrane 
is  likely  to  be  opened  in  the  operation,  they  should  not  be 
removed  unless  they  produce  grave  interference.  It  should 
always  be  remembered  that  in  removing  osteomata  and  exos- 
toses, the  cancellous  tissue  of  the  bone  from  which  they  grow 
is  opened.  Sub-ungual  exostoses  are  best  treated  by  removing 
the  nail,  then  exposing  the  base  of  the  bony  projection 
and  detaching  it  from  the  phalanx  Avith  cutting  forceps. 

*  Spencer  Watson  reported  a  case  on  which  Fergusson  operated  which  illus- 
trates this  fact.     Trans.  Path.  Soc,  vol.  xix.  310. 


SI 


CHAPTER     IV. 

ODONTOMATA   (TOOTH   TUMOURS). 

An  Odontome  is  a  tumour  composed  of  dental  tissues  in 
varying  proportions  and  different  degrees  of  development, 
arising  from  teeth-germs,  or  teeth  still  in  the  process  of 
growth. 

The  species  of  this  genus  are  determined  according  to  the 
part  of  the  tooth-germ  concerned  in  their  formation. 

1.  Epithelial  odontome  :  from  the  enamel-organ. 

2.  Follicular  odontome  ^ 

3.  Fibrous  odontome  |      From  the  tooth- 

4.  Cementome  1  follicle. 

5.  Compound  follicular  odontomeJ 

6.  Radicular  odontome  :  from  the  papilla. 

7.  Composite  odontome  :  from  the  whole  germ. 

1.  Epithelial  Odontomes. — These  tumours  occur,  as  a  rule, 
in  the  mandible,  but  they  have  been  observed  in  the  maxilla. 


Fig.  19.— Epithelial  odoiitoii 


(Nut.  size.) 


They  have  a  fairly  firm  capsule,  and  in  section  display  a 
congeries  of  cysts  of  various  shapes  and  sizes  ;  but  the  loculi 
rarely  exceed  2  cm.  in  diameter.  The  cysts  are  separated  by 
thin  fibrous  septa,  sometimes  ossified.  The  cavities  contain 
mucoid  fluid  of  a  brownish  colour.  The  growing  portions  of 
the  tumour  have  a  reddish  tint  not  unlike  a  myeloid  sarcoma 
(Fig.  19). 

Histologically,  an  epithelial  odontome  consists  of  branching 
and  anastomosing  columns  of  epithelium,  portions  of  which 


32 


CONNECJTIVE   T I  SHITE   TUMOIJBH. 


form  alveoli.  (Fig.  20.)  The  cells  occupying  the  alveoli  vary; 
the  outer  layer  may  be  columnar,  whilst  the  central  cells 
degenerate  and  give  rise  to  tissue  resembling  the  stratum 
intermedium  of  an  enamel-organ. 

Odontomes  of  this  species  are  most  frequent  about  the 
twentieth  year,  but  they  may  occur  at  any  age. 

The  tumours  have  been  investigated  by  Eve  (who  gave 
them  the  name  of  multilocular  cystic  epithelial  tumour)  and 
by  Falkson  and  Bryck.  They  probably  arise  from  persistent 
portions  of  the  epithelium  of  enamel-organs. 

2.  Follicular  Odontomes. — This  species  comprises  those 


Fig.  20.— Microscopical  characters  of  an  epithelial  odontome. 

swellings  often  called  dentigerous  cysts,  a  term  which  has 
come  to  be  used  very  loosely.  Follicular  odontomes  arise 
commonly  in  connection  with  teeth  of  the  permanent  set,  and 
especially  with  the  molars.  Sometimes  these  tumours  attain 
large  dimensions,  and  produce  great  deformity.  The  tumour 
consists  of  a  wall  of  a  varying  thickness,  which  represents  an 
expanded  tooth-follicle  ;  in  some  cases  it  is  thin  and  crepitant, 
in  others  it  may  be  1  cm.  thick.  The  cavity  of  the  cyst 
usually  contains  viscid  fluid  and  the  crown  or  the  root  of  an 
imperfectly  developed  tooth ;  occasionally  the  tooth  is  loose  in 
the  follicle,  sometimes  inverted,  and  often  its  root  is  truncated 
(Fig.  21);  exceptionally  the  tooth  is  absent.  The  walls  of  the 
cyst  always  contain  calcific  or  osseous  matter ;  the  amount 
varies  considerably.  Follicular  odontomes  rarely  suppurate. 
These  tumours  are  not  unknown  in  other  mammals  :  I 


ODONTOMATA. 


33 


have  seen  tliem  in  lambs,  pigs,  and  porcupines.  C.  Tomes  has 
suggested  that  these  cysts  are  probably  due  to  the  excessive 
formation  around  a  retained  tooth, 
between  it  and  the  wall  of  the  fol- 
licle, of  a  fluid  which  is  normally 
present  after  the  complete  develop- 
ment of  a  tooth. 

3.  Fibrous  Odontomes. — ^In  a 
developing  tooth,  a  portion  of  the 
connective  tissue  in  which  it  is  em- 
bedded, is  found  to  be  denser  and 
more  vascular  than  the  rest ;  it 
also  presents  a  fibrillar  arrange- 
ment. This  condensed  tissue  is  known  as  the  tooth-sac,  and 
when  fully  developed  presents  an  outer  firm  Avail  and  an 
inner  looser  layer  of  tissue.  At  the  root  of  the  tooth 
the  follicle-wall  blends  with  the  dentine  papilla,  and  is 
indistinguishable  from  it  Before  the  tooth  cuts  the  gum  it 
is  completely  enclosed  within  this  capsule.      Under   certain 


Fig.  21. — Follicular  odontome  (denti- 
gerous  cyst).  The  tooth  has  a  trun- 
cated root.    {Nat.  size.) 


Fig.  22. — Fibrous  odontome  from  a  goat.     {Nat.  size.) 

conditions  this  capsule  becomes  greatly  increased  in  thick- 
ness, and  so  thoroughly  encysts  the  tooth  that  it  is  never 
erupted  (Fig.  22).  Such  thickened  capsules  are  mistaken  for 
fibrous  tumours,  especially  if  the  tooth  be  small  and  ill- 
developed.  Under  the  microscope  they  present  a  laminated 
appearance,  with  strata  of  calcareous  matter.  To  these,  the  term 
fibrous  odontomes  may  be  applied.  They  are  more  common  in 
ruminants  than  in  other  mammals,  and  are  especially  frequent 

D 


34 


CONNECTIVE     TISSUE     TUMOUBS. 


in  goats.  As  a  rule  they  are  multiple,  four  being  by  no  means 
an  unusual  number.  Tliey  occur  in  marsupials,  bears,  and 
lions,  as  well  as  in  the  human  subject. 

There  is  good  reason  for  the  belief  that  rickets  is  respon- 
sible for  some  of  these  thickened  capsules.  That  the  tooth- 
sac  should  thicken  in  rickety  children  need  not  surprise  us 
when  we  remember  that  this  remarkable  disease  affects  most 
particularly  those  membranes  engaged  in  the  production  of 
bone.  Such  thickenings  of  the  follicles  occur  in  rickety 
children,  as  the  following  description  of  a  specimen,  preserved 
in  tlie  museum  of  the  Royal  College  of  Surgeons,  testifies.  It 
runs  thus  in  the  catalogue  :  "  Sections  of  two  myeloid  tumours 
developed  sj-mmetrically  in  the  angles  of  the  lower  jaw.  Their 
surfaces  are  covered  by  the  external  layer  of  compact  tissue  of 
the  bone  which  they  have  expanded  and  thinned." 

These  tumours  were  removed  by  Mr.  Heath  from  a  boy 
seven  and  a  half  years  old,  with  rickety  legs,  but  he  was 
well  nourished  when  the  tumours  were  removed;  they  were 


Fig.  23. — Cementome  from  a  horse.     {Half  nat.  size.) 

observed  when  he  was  two  and  a  half  years  old.  After  a  care- 
ful examination  of  these  tumours  I  have  no  hesitation  in 
declaring  them  to  be  thickened  tooth -follicles  —  fibrous 
odontomes. 

4.  Cementomes. — When  the  capsule  of  a  tooth  becomes 
enlarged,    as   in   the    specimens  just    considered,   and    these 


ODONTOMATA. 


35 


thick  capsules  ossify,  the  tooth  will  become  embedded  in  a 
mass  of  cementum.  To  this  form  of  odontome  the  name 
cementoma  may  be  applied.  Odontomes  of  this  character 
occur  most  frequently  in  horses,  and  sometimes  attain  a  large 
size.  Broca*  has  described  and  figured  specimens  from  horses. 
Mr.  Charles  Tomes  f  has  described  one  which  weighed  ten 


-Compound  follicular  odontome  from  a  Thar  (Capra  jemlaica) . 
maxillary  division  of  the  fifth  nerve.     {Nat.  size.) 


N,  Superior 


ounces,  and  I  have  given  an  account  of  another  which 
weighed  twenty-five  ounces.  The  main  portion  of  this  odon- 
tome is  sketched  in  Fig.  23.  When  divided,  three  teeth  could 
be  made  out,  embedded  in  cementum.  The  periphery  of  the 
tumour  was  cautiously  decalcified  in  hydrochloric  acid,  and 
sections  were  prepared  for  the  microscope.  The  structure  of 
the  decalcified  mass  was  very  instructive,  for  the  periphery  of 
the  tumour  exhibited  the  laminated  disposition  seen  in  fibrous 
odontomes. 

The  largest  cementome  from  a  horse  known  to  me  is  pre- 
served in  the  museum  of  the  Royal  Veterinary  (JoUege, 
London  ;  it  weighs  seventy  ounces,  and  though  excessively 
dense,   is   nevertheless   very   vascular.      Its   chief  structural 

*  "Traite  des  Tumeurs,"  t.  ii.,  p.  350,  1869. 

t  Trans.  Odont.  Soc.  Great  Britain,  1872,  p.  103. 


36  CONNECTIVE     TISSUE     TUMOURS. 

peculiarity   is  the  presence,  in  enormous  numbers,  of  large, 
richly  branched  lacunas.* 

5.  Compound  Follicular  Odontomes. — If  the  thickened 
capsule  ossilies  sporadically  instead  of  en  masse  a  curious  con- 
dition is  brought  about,  for  the  tumour  will  then  contain  a 
number  of  small  teeth  or  denticles  consisting  of  cementum, 
or  dentine,  or  even  ill-shaped  teeth  comjDOsed  of  three  dental 
elements,  cementum,  dentine,  and  enamel.  The  number  of 
teeth  and  denticles  in  such  tumours  varies  greatly,  and  may 
reach  a  total  of  three  or  four  hundred.  The  odontome 
sketched  in  Fig.  24  was  of  this  nature.  I  obtained  it  from  a 
Thar  or  Himalayan  goat,  which  had  one  in  each  upper  jaw. 
The  interior  of  each  tumour  was  occupied  with  teeth,  denticles, 
and  fragments  of  cementum  of  varying  size,  numbering  in  all 
three  hundred.  This  odontome  is  preserved  in  the  museum 
of  the  Koyal  College  of  Surgeons.     The  shape  and  size  of  the 


Fig.  25. — Denticles  from  the  odontome  of  a  Thar.     (Nat.  size.) 

denticles  may  be  inferred  from  those  sketched  in  Fig.  25. 
These  fragments  were  firmlj-  embedded  in  the  fibrous  walls  of 
the  tumour,  whilst  those  which  were  free  in  the  sac  had 
become  loosened  by  suppuration. 

Tumours  of  this  character  have  been  described  in  the 
human  subject  by  several  observers.  Amongst  the  most  note- 
worthy are  the  following : — 

Tellander,  of  Stockholm,  met  with  a  case  in  a  woman  aged 
twenty-seven  years.  The  right  upper  first  molar,  bicuspids, 
and  canine  of  the  permanent  set  had  not  erupted,  but  the  spot 
where  these  teeth  should  have  been  was  occupied  by  a  hard, 
painless  enlargement,  which  the  patient  had  noticed  since  the 
age  of  twelve  years.     Subsequently  this  swelling  was  found  to 

*  Trans.  Odont.  Soc.  Great  Britain,  1891,  p.  215. 


ODONTOMATA. 


37 


contain  minute  teeth.  There  were  nine  single  teeth,  each  one 
perfect  in  itself,  having  a  conical  root  with  a  conical  crown — 
tipped  with  enamel ;  also  six  masses  built  up  of  adherent  single 
teeth.  The  denticles  presented  the  usual  characters  of  super- 
numerary teeth.  About  a  year  afterwards  a  tooth  was  found 
making   its  appearance  in  the  spot  from  which  the  host  of 


Fig.  26.— A,  Denticles  from  Tellander's  case.     Total  number,  twenty-eight. 
B,  ,,         from  Sims's  case.     Total  number,  forty, 

c,  ,,  from  Mathias's  ease.     Total  number,  fifteen. 

teeth  was  removed.     A  few  of  the  teeth  are  represented  in 
Fig.  26. 

A  similar  case  has  been  recorded  by  Sir  John  Tomes,  the 
details  of  which  were  communicated  to  him  by  Mr.  Mathias  * 
whilst  on  medical  service  in  India.  A  Hindoo,  aged  twenty, 
had  a  large  number  of  ill-formed  teeth  united.  Further  search 
was  instituted,  until  at  last  fifteen  masses  of  supernumerary 
teeth  and  bone  were  removed.  The  soft  parts  rapidly  healed, 
the  deformity  disappeared,  and  the  only  peculiarity  noticeable 
was  the  absence  of  the  central  and  lateral  incisors.    The  canines 

*  Trans.  Odont.  Soc.  Great  Biitain,  vol.  iii.,  p.  365. 


38 


CONNECTIVE     TISSUE     TUMOURS. 


occupied  their  usual  position.      A  few  of  the  fragments  are, 
shown  in  Fig.  26,  c. 

A  third  example  of  this  remarkable  condition  has  been  re- 
corded by  Professor  Windle  and  Mr.  Humphreys.*  The  case 
occurred  in  the  practice  of  Mr.  Sims  at  the  Dental  Hospital, 
Birmingham.  The  tumour  was  found  in  the  mouth  of  a  boy 
aged  ten  years  ;  neither  the  deciduous  nor  permanent  right 
lateral  incisor  or  canine  had  erupted.  The  space  thus  unoccu- 
pied was  filled  by  a  tumour  with  dense  unyielding  walls.     On 


Fig.  27.— Radicular  odoutome  from  human  subject,    a  represents  the  natural  size 
of  the  specimen.     (After  Salter.) 

opening  this  tumour   forty  small   denticles   of  curious   and 
irregular  forms  were  removed  (Fig.  26,  b). 

Albert  f  and  Hildebrand  X  have  observed  similar  cases, 
and  Logan  §  reported  an  example  from  the  maxilla  of  a 
horse  containing"  four  hundred  denticles. 


6.  Radicular  Odontomes. 


This  term  is  applied  to  odon- 
1887. 


*  Journal  of  Anat.  and  Fhysiology,  vol.  xxi 

t  Illustrated  Med.  Journal,  Aug.  10,  1889. 

:|;  "Zeitsch.  fiir  Chir.,"  bd.  xxxi.  282. 

§  Journal  of  Comp.  Med.  and  Surgery,  New  York,  1887, 


ODONTOMATA. 


39 


tomes  which  arise  after  the  crown  of  the  tooth  has  been  com- 
pleted, and  while  the  roots  are  in  the  process  of  formation. 
As  the  crown  of  the  tooth,  when  once  formed,  is  unalterable, 
it  naturally  follows  that  should  the  root  develop  an  odontome 
enamel  cannot  enter  into  its  composition ;  the  tumour  would 
consist  of  dentine  and  cementum  in  varying  proportions, 
these  two  tissues  being  the  result  of  the  activity  of  the  papilla. 
As  a  typical  radicular  odontome,  we  may  choose  the  well- 
known  specimen  described  by  Salter,  and  represented  in  Fig. 
27.  In  this  specimen  the  tumour  is  clearly  connected  with 
the  roots.  The  outer  layer  of  the  odontome  is  composed  of 
cementum  ;  within  this  is  a  layer  of  dentine,  deficient  in  the 
lower  part  of  the  tumour,  and  inside  this  is  a  nucleus  of 
calcified  pulp. 

Mr.  Hare,  of  Limerick,  removed  from  the  upper  jaw  of  a 
man  aged  forty-one  the  odontome  sketched  in  Fig.  28.  This 
specimen  was  originally  de- 
scribed by  Sir  John  Tomes,* 
but  it  was  examined  and  re- 
described  by  Mr.  Charles 
Tomes,  t  The  mass  is  in- 
vested by  cementum  ;  inside 
this  casing  is  a  shell  of  den- 
tine ;  the  tubules  radiate  out- 
wards and  are  disposed  with 

some  regularity :  this  dentine  was  deficient  at  the  distal  end  of 
the  tumour  ;  its  interior  was  filled  with  an  ill-defined  osseous 

material. 

Radicular  odontomes  are 
rare  in  man,  but  frequent  in 
other  mammals,  and  are  often 
multiple.  Rodents  are  especi- 
ally liable  to  them,  due  in  a 
large  measure  to  the  fact  that 
their  teeth  grow  from  persis- 
tent pulps.  A  young  marmot 
had  four  odontomes,  one  attached  to  each  incisor  in  the  upper 
and  lower  jaw.      One  of  them  is  sketched  in  situ  (Fig.  29) 

*  Trans.  Odont.  Soc.  Great  Britain,  1863. 
t  Trans.  Odont.  Soc.  Great  Britain,  1372. 


Fig.  28. — Radicular  odontome.     (Nat.  size.) 
(After  John  Tomes.) 


Fig.  29. — Left  lower  .jaw  of  a  young  marmot 
with  a  large  radicular  odontome  connected 
with  the  incisor.     {Nat.  size.) 


40 


CONNECT  I VE     TISSUE     TUMOURS. 


and  of  natural  size.  It  consisted  mainly  of  ccmentum.  A 
similar  tumour  from  a  Canadian  porcupine  is  shown  in  Fig.  30. 
It  consisted  mainly  of  dentine.     The  tumour  was  lodged  in  a 


Fig.  30.— Lower  jaw  of  an  adult  Canadkii.  }!!,!'„u^!.!„.     A  i^Jieular  odontome  is 
attached  to  its  lower  incisor.     (Nat.  size.) 

large  pus-containing  cavity,  and  the  surrounding  bone  was 
bare  and  dead.  I  have  recorded  a  similar  specimen  in  an 
agouti.  In  all  these  cases  death  was  probably  due  to  the 
profuse  suppuration  set  up  by  the  odontomes,  the  pus,  being 
drawn  into  the  air-passages,  setting  up  septic  pneumonia. 

Radicular  odontomes  have  been  obtained  from  elephants, 
arising  in  connection  with  the  roots  of  the  tusks  ;  indeed,  the 
largest  odontomes  on  record  were  obtained  from  elephants. 
The  museum  of  the  Royal  College  of  Surgeons  contains  several 
excellent  specimens.  Structurally  they  consist  almost  entirely 
of  osteo-dentine.      A  radicular  odontome  described  by  Windle 


Fig.  -31. — Two  di'awings  of  a  radicular  cenientome,  from  a  man  aged  twenty-five 
years.     (Nat.  size.) 

and  Humphreys  is  represented  in  Fig.  31.     It  was  obtained 
from  a  man  twenty-five  years  of  age. 

This  odontome  was  situated  in  the  lower  jaw,  on  the  right 
side,  in  the  neighbourhood  of  the  second  molar  tooth.  After 
more  than  four  months'  excruciating  pain,  accompanied  with 
profuse  suppuration,  life  being  several  times  despaired  of,  the 
odontome,  seven  months  after  its  presence  was  first  noticed, 


ODONTOMATA.  41 

became  liberated  and  fell  into  the  month.  The  crown  is  fairly 
well  formed,  the  labial  surface  being  perfect,  the  lingual  some- 
what tuberculated.  The  roots  are  fused  into  a  shapeless  mass. 
The  under  surface  is  irregular,  and  at  one  point  presents  an 
excavation.  It  is  much  to  be  regretted  that  it  was  impossible 
to  obtain  sections  of  this  interesting  tumour. 

7.  Composite  Odontomes. — This  is  a  convenient  term  to 
apply  to  those  hard  tooth  tumours  which  bear  little  or  no 
resemblance  in  shape  to  teeth,  but  occur  in  the  jaws,  and 
consist  of  a  disordered  conglomeration  of  enamel,  dentine,  and 
cementum.  Such  odontomes  may  be  considered  as  arising 
from  an  abnormal  growth  of  all  the  elements  of  a  tooth-germ — 
enamel-organ,  papilla,  and  follicle. 

Not  only  is  this  class  of  odontomes  composite  in  that  the 
tumours  comprised  in  it  originate  from  all  the  elements  of  a 
tooth-germ,  but  they  are  composite  in  another  sense.  In  the 
majority  of  cases  the  tumours  are  composed  of  two  or  more 
tooth-germs  indiscriminately  fused.  But  they  differ  from  the 
cementomata  containing  two  or  more  teeth,  in  the  fact  that 
the  various  parts  of  the  teeth  composing  the  mass  are  in- 
distinguishably  mixed,  whereas  the  individual  teeth  implicated 
in  a  cementoma  can  be  clearly  defined. 

Up  to  the  present  time  I  have  found  no  such  odontomes 
in  the  lower  mammals,  all  the  recorded  cases  having  occurred 
in  man.  A  typical  odontome  of  this  group  is  the  one  described 
by  Mr.  Heath*  as  occurring  in  the  lower  jaw  of  a  young  lady, 


Fig.  32. — Composite  odontome  from  a  young  lady  aged  eighteen.     {Nat.  size.)    {After  Heath.) 

aged  eighteen.  The  clinical  history  in  this  case  is  very  in- 
structive, and  the  reader  is  referred  to  the  original  account  of 
it.     (Fig.  32.) 

*  Clinical  Society's  Transaction?,  vol.  xv.  10. 


42 


CONNECTIVE     TISSUE     TUMOURS. 


The  specimen  is  further  vahiable  on  account  of  the 
exhaustive  and  careful  histological  examination  made  by  Mr. 
Charles  Tomes,  who  found  it  composed  of  enamel,  dentine, 
and  osteo-dentine. 

Forget's  classical  case  belongs  to  this  species.  The 
patient  was  twenty  years  old,  but  the  disease  had  been  noticed 
since  the  age  of  five  years.  Behind  the  first  bicuspid  no 
teeth  were  seen,  but  the  jaw  as  far  back  as  the  ramus  was  the 
seat  of  a  smooth,  unyielding  tumour.  The  parts  represented 
in  the  figure  were  removed  during  life.  (Fig.  33.)  On  micro- 
scopical examination  the  tumour  consisted  mainly  of  dentine, 
the   surface   of  which   was   in   places   covered  with   enamel 


Fig.  33. — Composite  odontome.     (Nat.  size.)    (After  Forget.) 

dipping  into  the  crevices,  at  the  bottom  of  which  cementum 
was  found. 

The  Transactions  of  the  Pathological  Society,  London, 
though  a  mine  of  wealth  in  most  kinds  of  tumours,  contain 
only  one  description  of  an  odontome ;  it  is  described  by  Mr. 
Rushton  Parker.*  The  specimen  originated  in  connection 
with  the  second  left  lower  molar  of  a  lady  aged  nineteen 
years.  An  effort  was  made  to  extract  the  tooth,  but  it 
broke,  leaving  the  tumour  behind.  Subsequently  an  attempt 
made  to  extract  the  mass  failed,  a  few  fragments  only  being 
detached  ;  about  two  years  later  it  issued  spontaneously  from 

*  Trr.ns.  Path.  Soc,  vol.  xxxii.  240. 


ODONTOMATA. 


43 


the   alveolus.     The  odontome,  which   weighs    136  grains,  is 
represented   in   Fig.    34,  taken   from   a 
drawing   kindly   furnished   me   by   Mr. 
Rushton  Parker. 

In  the  same  category  may  be  placed 
the  odontome  dislodged  by  Professor 
Annanclale*  from  the  lower  jaw  of  a  girl 
aged  seventeen.  It  weighed  300  grains, 
and  consisted  of  dentine  and  osteo- 
dentine  capped  by  enamel. 

Nine  months  before  the  patient  was 
seen  by  Mr.  Annandale,  an  abscess  formed  over  the  top  of 
the  swelling,  from  which  the  odontome  was  ultimately  dis- 
lodged ;  the  abscess  left  a  chronic  sinus  from  which  small 
quantities  of  pus  issued  up  to  the  time  of  the  operation.  No 
molar  teeth  were  erupted  in  the  right  lower  jaw,  their  position 
being   occupied   by  the   odontome.     The  cavity  left  by  the 


Fig.  34  —Odontome 

(Xut.  ■■yize.) 

{Mr.  Rushton  Parker's  case.) 


Fig.  35.— Odontome  from  the  npper  jaw.     (Nat.  size.)     {M.  Miclwn's  case.) 

dislodgment  of  the  tumour  was  lined  with  a  smooth,  velvety 
membrane. 

It  is  supposed  that  odontomes  are  more  frequent  in  the 
lower  than  the  upper  jaw,  but  there  is  good  ground  for  the 

*  Edin.  Med.  and  Surg.  Journal,  1873,  p.  699. 


u 


CONNECTIVE     TISSUE     TUMOURS. 


belief  that  many  such  tuinours  have  been  described  as  exostoses 
of  the  antrum.  Thus  M.  Michon  removed  from  the  antrum 
of  a  Frenchman,  aged  nineteen  years,  at  the  Hopital  de  la 
Pitie  (without  an  anaesthetic),  the  large  odontome  repre- 
sented in  Fig.  35.  The  operation,  which  may  be  described  as 
a  "  surgical  struggle,"  lasted  upwards  of  an  hour  and  a 
quarter. 

The  tumour  is  described  as  an  exostosis,  but  fortunately 
M.  Michon's  account  is  accompanied  by  some  excellent 
figures  which  show  clearly  enough  that  the  tumour  is  an 
odontome.  The  cut  surface  exhibited  a  laminated  disposition. 
Microscopically  it  was  composed  of  tissue  presenting  many 
parallel  tubules  having  the  appearance  of  exaggerated  dentinal 
tubes.  It  is  the  largest  odontome  but  one  from  man  of 
which  we  have  any  record  ;  its  weight  is  1,080  grains.* 

A  tumour  almost  parallel  with  that  of  M.  Michon  has  been 
described  by  Dr.  T.  Duka,|  by  whom  it  was  removed  from  a 
Mahomedan    woman,   aged    twenty-six    years,   at    Monghyr, 


Fig.  3C. — Composite  odontome  from  the  upper  jaw.     (Kat.  size.)     {Dr.  Duka's  case.) 


Bengal.  The  woman  had  for  six  years  suffered  from  a  muco- 
purulent discharge  from  the  right  nostril,  and  was  now 
anxious  for  relief  The  case  was  regarded  as  one  of  necrosis, 
but  after  a  "  surgical  struggle  "  lasting  ner.rly  an  hour  without 

*  Mem.  de  la  Societe  de  la  Chir.,  Paris,  1850. 
t  Trans.  Path.  Soc,  vol.  xvii.  256. 


ODONTOMATA.  45 

chloroform,  the  tumour  represented  m  Fig.  36  was  withdrawn 
from  the  antrum.  It  had  no  connection  with  the  surround- 
ing tissues. 

The  tumour,  which  was  regarded  as  an  exostosis,  was  sub- 
mitted to  a  committee  of  the  Pathological  Society.  In  its 
report  this  committee  states  that  the  bone  tissue  differs  in 
character  from  that  ordinarily  seen  in  exostoses.  An  examina- 
tion of  the  tumour,  which  is  preserved  in  St.  George's  Hospital 
museum,  and  an  inspection  of  the  figures  illustrating  the 
above-mentioned  report,  show  clearly  enough  that  it  is  a  com- 
posite odontome.  Dr.  Duka,  in  his  account  of  the  case,  states 
that  Dr.  Allen  Webb  was  of  opinion  that  the  nucleus  was 
formed  by  a  tooth-follicle  escaping  into  the  antrum  of 
Highmore.  This  was  a  guess,  but  one  not  far  short  of  the 
truth. 

The  largest  odontome  known  to  have  grown  in  the  human 
antrum,  and  which  for  many  years  has  been  regarded  as  an 
exostosis,  is  preserved  in  the  museum  of  Guy's  Hospital.  It 
has  an  extraordinary  clinical  history  which  was  recorded  by 
Hilton.*     (Fig.  37.) 

The  patient,  a  man  aged  thirty-six  years,  had  a  large 
osseous  tumour  occupying  the  antrum.  The  pressure  of  this 
tumour  had  caused  the  front  wall  of  the  antrum,  with  the  in- 
tegument and  soft  tissues  covering  it,  to  slough.  The  trouble 
was  first  noticed  thirteen  years  before ;  as  the  cheek  enlarged 
the  eyeball  became  displaced  and  finally  burst.  For  a  long 
time  the  surface  of  the  tumour  was  exposed,  the  suppuration 
being  copious,  and  occasionally  pieces  of  bone  irregular  in 
shape  came  away ;  at  last,  to  the  man's  astonishment,  the  bony 
mass  drop23ed  out,  leaving  an  enormous  hole  in  his  face.  The 
general  appearance  of  this  tumour  may  be  inferred  from  the 
accompanying  sketch.  It  weighed  nearly  fifteen  ounces,  and 
measured  27'5  cm.  (11")  in  its  greatest  circumference.  I  have 
had  an  opportunity  of  investigating  this  tumour  ;  it  is  remark- 
ably hard,  presents  on  section  an  ivory -like  surface  and,  on 
close  scrutiny,  a  number  of  closely-arranged  concentric  laminae. 
(Fig.  38.)  Sections  ground  thin  and  examined  under  the 
microscope  show  large  numbers  of  lacunse  and  canaliculi 
arranged  in    a  very   regular   manner.       I    could   not   detect 

*  Guy's  Hospital  Eeports,  vol.  i.,  p.  493,  1836. 


46 


CONNECTIVE     TISSUE     TUMOURS. 


dentine,  and  it  is  impossible,  without  mutilating  the  specimen, 
to  be  sure  that  no  teeth  are  embedded  in  it. 

As  this  tumour  had  no  bony  connections,  occupied  the 


Fig.  37.— Large  odoiitome  which  was  spontaneously  shed  from  the  antrum;  weight,  nearly 
fifteen  ounces.     Hilton's  case.     {From  the  Museum  of  Guy's  HospitoJ.) 

antrum,  and  in  the  structure  of  its  peripheral  parts  is  so  closely 
identical  with  odontomes  which  occur  in  horses,  there  need 
be   no   hesitation    in   believing  that  this  particular  tumour 


Fig.  38. — Section  of  the  tumour  represented  in  Fig.  37  to  .show  the  concentric  lamination. 


ODONTOMATA. 


47 


originated  in  one  or  more  enlarged  tooth-follicles,  and  is  in 
fact  an  odontome. 

Mr.  Jordan  Lloyd*  has  published  an  excellent  account  of 
an  odontome  of  this  class  which  he  removed  from  the  right 
upper  jaw  of  a  young  man.  As  so  often  happens,  the  case  was 
regarded  as  one  of  necrosis,  but  when  removed  from  its  bed 
was  recognised  as  an  odontome.    The  tumour  (Fig.  39)  weighed 


Fig.  39.  —Composite  odontome  from  tlie  upper  jaw.     {Nat.  size.)    The  left-liand  figure 
shows  the  tumour  in  section.    (Mr.  Jordan  Lloyd's  case.) 


279  grains  ;  it  is  composed  of  osteo-dentine,  with  cementum 
here  and  there.  Opaline,  pearly  patches  are  studded  irregu- 
larly around  the  edge  of  the  cut  surface.  The  mass  occupied 
the  space  of  the  second,  and  probably  the  third,  right  upper 
molars ;  it  could  be  felt  to  be  slightly  loose  before  attempts 
were  made  to  remove  it.  After  its  extraction  a  deep,  round, 
smooth,  velvet-like  cavity  remained,  and  the  exposed  part, 
with  its  crater-like  hollow  and  surrounding!'  riclo'e,  bore  a 
certain  resemblance  to  a  molar  tooth  crown. 

The  odontome  represented  in  Fig.  40  was 
removed  by  Mr.  S.  Brock  from  a  lad  aged  nine- 
teen years  ;  it  was  situated  in  front  of  the  right 
upper  bicuspid,  displacing   the   lateral   incisor 
and  canine  so  as  to  occupy  their  position  in  the 
dental  arch.     As  will  be  seen  in  the  figure,  it 
appears  to  consist  merely  of  a  crown  and  neck, 
but  the  crown  bristles  with  cusps  ;   as  many  as 
nine  distinct  enamel-covered  eminences  can  be 
detected.     Odontomes  resemble  teeth  in  this  way — for  a  time 
during   their   development    they   remain   hidden   below    the 
mucous   membrane,  and  give  little  or  no  evidence  of  their 
existence.       To    this   succeeds   an    eruptive    stage,   and    the 

*  lancet,  1888,  vol.  i.,  p.  64. 


Fig.  40.— Odontome 
from  the  upper 
jaw.  (It  is  slight- 
ly enlarged  in  the 
sketch.) 


48  CONNECTIVE     TISHUE     TUMOURS. 

suppuration,  with  the  constitutional  disturbance  dependent 
thereon,  draws  attention  to  them.  This  remarkable  odontoma 
had  not  only  cut  the  gum  but  had  taken  a  position  in  the 
dental  series,  and  is  further  interesting  in  that  it  consists 
of  a  conglomeration  of  denticles,  for  I  have  urged  that  those 
remarkable  cases  in  which  denticles  have  from  time  to  time 
been  erupted  from  a  tumour  connected  with  the  jaw  should  be 
classed  as  odontomes.  It  is  easy  to  imagine  that  if  the  cusps 
of  this  odontome  remained  distinct,  and  each  had  been  sepa- 
rately erupted,  they  would  have  been  called  supernumerary 
teeth.  Indeed,  many  of  the  cusps  can  be  easily  detached  from 
the  main  mass.  Thus  this  strange  specimen  serves  to  bridge 
the  gap  between  compound  follicular  and  composite  odontomes. 

Treatment. — A  study  of  the  literature  relating  to  odon- 
tomes is  very  instructive,  for  it  serves  to  show  that  patients 
have  in  many  instances  been  submitted  to  operations  need- 
lessly severe  and  dangerous.  It  is  a  curious  fact  that  up  to 
this  date  there  is  no  instance  on  record  in  which  an 
odontome,  other  than  a  follicular  cyst,  has  been  diagnosed  be- 
fore operation.  In  some  cases  the  trouble  has  been  regarded 
as  due.  to  necrosed  bone,  or  unerupted  teeth ;  in  a  few  the 
tumours  were  regarded  as  exostoses,  whilst  several  fibrous 
odontomes  have  been  described  as  myeloid  sarcomata. 

In  the  case  of  a  tumour  of  the  jaw,  the  nature  of  which  is 
doubtful,  particularly  in  a  young  adult,  it  is  incumbent  on  the 
surgeon  to  satisfy  himself  before  proceeding  to  excise  a  portion 
of  the  mandible  or  maxilla  that  the  tumour  is  not  an  odontome, 
for  this  kind  of  tumour  only  requires  enucleation.  In  the  case 
of  a  follicular  odontome  it  is  usually  sufficient  to  excise  a  por- 
tion of  its  wall,  scrape  out  the  cavity,  remove  the  tooth  if  one 
be  present,  stuff'  the  sac,  and  allow  it  to  close  by  the  process  of 
granulation. 


49 


CHAPTER     Y 

FIBROMATA. 


Fibromata,  or  tinnours  composed  of  fibrous  tissue,  were 
formerly  supposed  to  be  very  common,  but  careful  histological 
research  has  shown  that  tumours  consisting  almost  entirely  of 
fibrous  tissue  are  somewhat  rare.  For  instance,  it  was  the 
fashion  to  describe  as  fibromata  those  tumours  of  the  uterus 
now  known  as  myomata  and  fibro-myomata ;  traces  of  this 
belief  linger  still,  for  some  yet  write  of  them  as  "  uterine 
fibroids."  Many  tumours  now  recognised  as  spmdle-celled 
sarcomata  were,  a  few  years  ago,  named  "  recurring  fibroid 
tumours."  The  difiiculty  of  distinguishing  between  a  myoma, 
a  slowly  growing  spindle-celled  sarcoma,  and  a  pure  fibroma 
is  well  known  to  skilled  histologists ;  when  a  tumour  com- 
posed of  slender  fusiform  cells  occurs  in  such  an  organ  as 
the  ovary,  where  myomata,  fibromata,  and  sarcomata  also 
occur,  the  distinction  on  histological  grounds  alone  is  often 
impossible. 

In  slow-growing  fibromata  there  is  not  much  difficulty,  but 
in  softer  forms  it  often  becomes  a  matter  of  importance  to  de- 
cide between  a  fibroma  and  a  spindle-celled  sarcoma.  It  is  a 
matter  of  less  moment  to  decide  betAveen  a  myoma  and  a 
fibroma,  as  both  are  innocent  tumours,  and  it  is  probable  that 
some  uterine  tumours  begin  as  myomata  and  degenerate  into 
fibrous  tissue. 

Typical  fibromata  are  generally  dense  tumours  consisting 
of  wavy  bundles  of  fibrous  tissue.  The  bundles  are  composed 
of  long,  slender,  fusiform  cells  closely  packed  together.  The 
tissue  of  the  tumours,  often  arranged  in  whorls,  is  permeated 
by  bloodvessels. 

Fibromata  occur  in  the  following  situations : — The  ovary, 
uterus,  intestine,  the  gum  (epulis),  as  laryngeal  polypi,  on  the 
sheath  of  nerves  (neuromata)  and  in  the  subcutaneous  tissues 
as  "  painful  subcutaneous  tubercles  " ;  and  in  the  condition 
termed  moUuscum  fibrosum. 

There  is  a  spurious  form  of  tumour  known  as  keloid  which 
E 


50  CONNECTIVE     TISSUE     TUMOUBS. 

stands  in  the  same  relation  to  a  fibroma  that  an  exostosis  bears 
to  an  osteoma. 

The  chief  species  of  fibromata  are  :■ — -1,  Simple  fibromata  ; 
2,  molluscum  fibrosum  ;  3,  neuro-fibromata. 

In  this  section  simple  fibromata,  epulis,  and  molluscum 
fibrosum  will  be  considered.  Neuro-fibromata  will  be  described 
with  neuromata. 

1.  Simple  Fibromata. — A  most  interesting  and  certainly 
a  very  frequent  variety  of  fibroma  is  the  small  nodules 
so  often  met  with  in  the  subcutaneous  tissues  of  the 
trunk,  and  especially  the  limbs,  described  and  named  by 
Wood*  the  Painful  Subcutaneous  Tubercle  in  the  following' 
words : — 

"  This  disease  consists  in  the  formation  of  a  tubercle  of 
peculiar  nature  in  the  subcutaneous  cellular  substance.  This 
tubercle  is  met  with  in  different  parts  of  the  body,  but  most 
frequently  in  the  extremities.  It  is  extremely  small,  generally 
of  the  size  and  form  of  a  flattened  garden  pea,  and  in  none  of 
the  cases  of  which  I  have  been  able  to  procure  a  distinct 
account,  larger  than  a  coffee-bean.  It  is  of  firm  consistence, 
and  is  apparently  quite  circumscribed,  being  situated  loosely 
in  the  cellular  substance,  immediately  under  the  integuments, 
which  retain  their  natural  colour  and  appearance.  In  the 
greater  proportion  of  cases  there  is  no  visible  appearance  of 
disease  whatever,  and  it  is  only  when  the  surgeon  applies  his 
finger  to  a  particular  spot  pointed  out  by  the  patient  that  he 
becomes  sensible  of  the  existence  of  the  tubercle.  In  some 
few  cases,  however,  although  small,  it  is  so  superficially  seated 
as  to  form  a  visible  prominence. 

"As  in  all  the  cases  with  which  I  am  acquainted,  the 
tubercle  had  attained  nearly  its  full  growth  before  its  presence 
was  detected.  I  am  unable  to  say  whether  it  is  originally  of 
slow  or  rapid  formation ;  but  having  acquired  a  certain  size,  it 
remains  nearly  stationary,  undergoing  hardly  any  perceptible 
increase  of  bulk,  even  in  the  course  of  a  great  many  years ;. 
nor  does  it  ever  show  any  tendency  to  affect  either  the  skin 
or  surrounding  cellular  substance. 

"  Trifling  as  the  diseased  part  is,  in  point  of  size  and  appear- 
ance, it  becomes  the  cause  of  very  severe  and  even  excruciating 

*  Edin.  Med.  and  Surg.  Journal,  1812,  p.  283. 


FIBROMATA.  51 

pain.  So  strongly  is  this  pain  represented  by  the  patients 
th.at  we  might  be  apt  to  imagine  their  statement  exaggerated, 
did  we  not  find  them  all  concurring  in  the  same  repre- 
sentation. 

"  The  pain  is  extremely  acute  in  the  tubercle,  and  extends 
from  it  to  a  considerable  distance  along  the  neighbouring 
parts ;  it  is  not  constant,  but  occurs  in  paroxysms.  In  general, 
at  the  commencement  of  the  paroxysm,  the  pain  is  slight,  but 
gradually  increases  until  it  becomes  excruciatingly  severe, 
and  it  goes  oft'  in  the  same  gradual  manner,  leaving  the  parts 
in  the  neighbourhood  of  the  tubercle,  for  some  time  after- 
wards, sore  to  the  touch,  as  if  they  had  been  bruised.  The 
paroxysms  vary  in  duration  from  ten  minutes  to  upwards  of 
two  hours  ;  but  they  seem  to  increase,  both  in  frequency  and 
severity,  in  proportion  to  the  length  of  time  the  disease  has 
existed. 

"  Some  of  the  patients  have  occasional  intervals  of  ease  for 
days  or  even  weeks ;  in  others  the  paroxysms  occur  several 
times  in  the  course  of  one  day.  They  generally  come  on  spon- 
taneously, but  in  some  of  the  cases  they  were  sometimes  in- 
duced by  the  friction  of  the  clothes  along  the  surface  of  the 
tubercle.  They  frequently  attack  the  patient  when  asleep,  in 
which  case  he  is  suddenly  awoke  by  the  severity  of  the  pain. 

"  The  degree  of  pain  produced  by  touching  the  tubercle  is 
different  in  different  cases.  Acute  pain  is  produced  at  all 
times  by  the  tubercle  being  accidentally  struck  against  any 
hard  substance. 

"  It  is  a  singular  circumstance  that  in  all  the  cases  which 
have  come  to  my  knowledge,  with  perhaps  one  exception, 
this  species  of  tubercle  occurred  in  females.  It  does  not 
appear  to  be  confined  to  any  particular  age,  but  is  frequently 
met  with  at  an  early  period  of  life,  and  I  have  known  it  to 
remain  nearly  unchanged  for  upwards  of  eighteen  years." 

Although  these  small  painful  tumours  have  been  abun- 
dantly studied  since  Wood  wrote  his  description  of  them,  no 
advance  has  been  made  in  our  knowledge  of  them.  It  has 
been  fully  demonstrated  that  they  are  found  four  or  five  times 
more  frequently  in  females  than  in  males.  From  the  extreme 
pain  produced  by  these  tubercles  many  have  imagined  that 
they  must  contain  nerve-fibrils ;  but  even  with  the  elaborate 


52  CONNECTIVE     TISSUE     TUMOURS. 

methods  of  modern  histology  no  one  has  succeeded  in  demon- 
strating their  existence.  The  removal  of  these  little  bodies  at 
once  arrests  the  paroxysms  of  pain. 

Ovarian  Fibromata. — Tumours,  sometimes  of  large  size, 
composed  of  fibrous  tissue  have,  in  a  few  rare  instances,  been 
demonstrated  in  the  ovary.  They  may  be  regarded  as  patho- 
logical curiosities. 

Uterine  Fibroinata. — Fibrous  tissue  often  forms  a  very 
large  proportion  of  many  uterine  myomata,  and  it  has  already 
been  mentioned  that  some  uterine  tumours,  apparently  con- 
sisting of  pure  fibrous  tissue,  were  probably  in  their  early 
stages  myomata  or  fibro-myomata. 

Intestinal  Fibromata. — From  what  is  known,  in  the 
light  of  modern  histology,  of  the  nature  of  tumours  springing 
from  the  walls  of  the  intestine,  it  seems  a  fair  inference  that 
many  specimens  reported  in  older  literature  as  "  fibrous 
tumours  "  were  in  reality  myomata. 

Laryngeal  Fibromata. — Small  polypoid  outgrowths  have 
in  a  few  instances  been  removed  from  the  mucous  membrane 
of  the  larynx ;  on  microscopical  examination  they  were  found 
to  consist  of  pure  fibrous  tissue. 

Epulis. — This  is  a  term  which  formerly  had  a  wide  signi- 
ficance. It  was  applied  to  almost  any  tumour  growing  upon 
the  gums ;  but  when  the  microscope  w^as  employed  to  assist 
in  the  classification  of  tumours  it  was  found  that  some  epulides 
were  sarcomatous,  others  fibrous,  a  few  myxomatous,  and  so 
on.  As  a  consequence  the  term  came  to  have  merely  a 
topographical  significance.  It  will  be  wise  to  restrict  the 
term  to  tumours  composed  of  fibrous  tissue  arising  from  the 
gums,  or  froiTL  the  periodontal  membrane.  These  tumours 
either  arise  in  connection  with  the  root  of  a  decayed  tooth,  or 
from  the  retained  root  of  a  carious  tooth  hidden  by  the  gums. 
An  epulis  of  this  character  is  made  up  of  fibrous  tissue  covered 
externally  with  the  gingival  mucous  membrane ;  it  may  be 
pedunculated  or  sessile,  and  occasionally  two  may  be  present. 
AVhen  freely  excised  and  the  stump,  or  carious  tooth,  with 
which  the  epulis  is  invariably  associated  removed,  it  rarely 
ever  returns.  Although  an  epulis  is  seldom  larger  than  a 
walnut,  it  may  attain  a  size  equal  to  the  closed  fist.  Such  a 
tumour  will  exercise  great  pressure  upon  the  dental  arches, 


FIBROMATA. 


53 


distort  the  cheek,  aUer  the  shape  of  the  maxilla  and  mandible, 
encroach  npon  the  palate,  and  even  protrude  between  the  lips. 
2.  MoUuscum  Fibrosum. — This  extraordinary  condition  of 
the  skin  and  subcutaneous  tissue  has  been  described  under  such 
names  as  Fihro-cellidar  Tumour,  Dermatolysis,  and  Pachy- 


\     X   v^ 


M' 


Fig.  41. — Case  of  inolluscum  fibrosum.     {After  Mott.) 

dermatocele.  The  chief  features  of  the  disease  consist  of  an 
overgrowth  of  the  skin  and  subcutaneous  tissue,  which  will 
affect  a  small  area  like  the  scalp,  or  may  involve  a  large  extent 
of  skin  on  the  trunk  and  limbs,  causing  it  to  hang  in  pendulous 
folds.  Sometimes  molluscum  fibrosum  assumes  the  form  of 
discrete  nodules  scattered  over  the  skin ;  these  nodules  vary 
in  size,  the  extremes  being  represented  by  a  pea  and  a  walnut. 


54  CONNECTIVE     TISSUE     TUMOURS. 

This  variety  of  the  disease  is  sometimes  associated  with 
similar  nodules  (neuromata)  scattered  upon  the  sheath  of 
nerves  in  various  parts  of  the  body.  (Plate  III.)  Exceptionally 
the  pendulous  and  nodular  lesions  occur  in  the  same  individual. 

The  histology  of  the  nodules  and  the  pendulous  flaps  is 
similar ;  the  condition  appears  to  be  due  to  an  overgrowth  of 
the  fibrous  tissue  of  the  skin  and  subcutaneous  tissue.  Con- 
cerning the  cause  of  this  overgrowth  nothing  is  known  ;  the 
disease  is  not  confined  to  any  clime  or  race,  for  it  has  been 
observed  in  North  America,  the  British  Isles,  Germany,  and  in 
natives  of  the  West  Coast  of  Africa. 

The  most  remarkable  series  of  cases  of  this  nature  is  re- 
corded by  Valentine  Mott*  under  the  name  of  Pachydermato- 
cele. One  case  will  serve  as  a  type.  The  patient,  a  single  lady 
forty-five  years  of  age,  when  she  came  under  Mott's  care  had  a 
large  tumour  of  a  copper  colour,  soft  and  elastic  to  the  touch, 
and  forming  five  folds  or  convolutions,  as  represented  in 
Fig.  41.  This  mass  was  attached  to  the  skin  directly  under 
the  lobule  of  the  ear,  to  the  side  of  the  neck,  the  thorax,  and 
abdomen  as  low  as  the  umbilicus  ;  it  extended  down  the  arm 
to  the  insertion  of  the  deltoid. 

The  mother  of  the  patient  stated  that  the  tumour  had  been 
noticed  soon  after  birth.  The  woman  was  anxious  to  have  the 
mass  removed.  During  the  operation  many  arteries  required 
ligatures,  and  some  were  of  considerable  size  ;  two  very  large 
veins  were  seen,  which  Mott  describes  as  the  largest  superficial 
veins  he  had  ever  seen;  they  terminated  in  the  subclavian. 
The  patient  recovered,  notwithstanding  two  attacks  of  ery- 
sipelas during  convalescence.  Five  years  later  the  patient 
Avas  in  perfect  health,  and  there  had  been  no  recurrence  of 
the  tumour.  Unfortunately  no  careful  account  of  the  his- 
tology of  the  tumour  is  forthcoming  beyond  the  statement 
that  "  the  specimen  appears  to  consist  of  a  hypertrophy  of  the 
skin  and  of  the  subcutaneous  cellular  tissue." 

Lamprey  f  recorded  a  case  of  dermatolysis  which  he 
observed  in  a  negro  in  a  street  of  Sierra  Leone.  He 
was  successful  in  obtaining  a  photograph.  (Fig.  42.)  A 
large  mass  of  skin  hangs  in  folds  from  the  back  and  left  side 

*  Medico-Chir.  Trans.,  vol.  xxxvii.,  p.  155. 
t  £rit.  Mai.  Journal,  1892,  vol.  i.,  p.  173. 


FIBROMATA. 


55 


of  the  head,  and  falls  over  the  left  shoulder  and  back.  In 
addition  to  the  scalp  tumour  there  are  numerous  nodules  on 
the  skin  of  the  trunk,  legs,  arms,  and  face,  varying  m  size 
from   a  peppercorn    to    a   billiard-ball,  some    of  which   had 


Fig.  42. — Native  of  Sierra  Leone,  aged  fifty,  witli  molluscum  fibrosum. 
{After  Lamprey.) 


ulcerated.  The  man  stated  that  he  was  born  with  lumps  on 
his  skin. 

As  the  case  resembled,  in  some  respects,  elephantiasis,  the 
blood  was  obtained  at  seven  p.m.  from  one  of  the  tumours,  and 
carefully  examined  for  filarial,  but  with  negative  results. 

For  other  cases  of  this  disease  the  following  references  may 


56 


CONNECTIVE     TISSUE     TUMOURS. 


be  consulted.*  The  disease  appears  to  be  equally  common  in 
women  and  men.  The  frontispiece  to  Band  I.  of  Virchow's 
"Die  Krankhaften  Geschwulste"  represents  a  case  of  dermato- 
lysis  associated  with  a  multitude  of  cutaneous  nodules  in  a 
woman  forty-seven  years  old,  under  the  title  of  "  fibrosum 
molluscum  multiplex." 

Keloid. — This   term   is   applied   to    formations    of    dense 
tibrous  tissue  which  arise  in  cicatrices  of  the  skin.     A  keloid 


^i. 


Fig.  43. — Keloid  in  the  lobule  of  the  pinna,  associated  with  an  ear-ring  puncture. 


projects  above  the  surface  of  the  skin  sometimes  to  the  extent 
of  a  centimetre ;  its  surface  is  quite  smooth,  and  may  be  white 
or  shining,  or  pink  from  the  number  of  dilated  vessels  coursing 
over  it.  Sometimes  the  tumour  has  a  regular  outline,  but,  as 
a  rule,  it  sends  out  spurlike  processes  into  the  adjacent  skin ; 
structurally  it  is  identical  with  cicatricial  tissue.  Though 
originating  in  scars,  keloid  is  not  always  limited  by  the  scar  in 
which  it  arises,  but  it  rarely  transgresses  to  any  great  extent 


*  Flower,  Lancet,  1860;  Treves,  Trans.  Path.  Soc,  vol.  xxxvi.  494  ;  Wright, 
Trans.  Path.  Soc,  xvi.  269;  Pollock,  Trans.  Path.  Soc,  xxvi.  219. 


FIBROMATA. 


57 


upon  the  healthy  skm.  When  a  keloid  is  excised,  in  the  ma- 
jority of  cases  it  returns  as  the  wound  heals,  and  very  generally 
the  scars  of  the  stitch-holes  become  the  seats  of  keloid  also. 

The  conditions  which  favour  the  production  of  keloid  are 
unknown  ;  it  occurs  fairly  frequently  in  the  scars  left  by  burns, 


Fig.  44. —  Unusual  case  of  keloid  in  a  coloured  woman.     (After  Taylor.) 

but  it  will  ensue  on  almost  any  kind  of  injury  to  the  skin.  It 
has  been  observed  in  the  scars  left  by  small-pox,  by  vaccination, 
primary  and  secondary ;  in  acne  scars  and  the  scars  of  leech- 
bites  ;  it  has  been  frequently  observed  in  cicatrices  the  result  of 
surgical  operations,  and  in  the  coarse  stripes  left  by  the  severe 
use  of  the  lash.  It  has  been  frequently  observed  in  the  lobule 
of  the  pinna  in  the  punctures  made  for  ear-rings,  in  white  and 


58  CONNECTIVE     TISSUE     TUMOURS. 

especially  in  black  races  of  mankind  (Fig.  48),  and  it  also 
occurs  in  the  scars  left  by  syphilitic  lesions.  Keloid  has  been 
observed  before  the  tenth  year  of  life,  but  this  is  uncommon ;  it 
is  most  frequently  met  with  in  adults,  and  becomes  very  rare 
in  old  age. 

The  tumour  J  when  it  makes  its  appearance,  slowly  pro- 
gresses up  to  a  certain  point,  remains  stationary  for  an  indefi- 
nite period,  in  some  cases  lasting  for  ten,  twenty,  or  even 
thirty  years,  then  slowly  disappearing.  It  is  said  that  involution 
of  keloid  occurs  quicker  in  the  young  than  in  those  advanced 
in  life. 

In  describing  keloid  it  is  customary  to  distinguish  a  true 
or  spontaneous  keloid  and  a  false  keloid.  The  true  variety 
was  supposed  to  arise  independently  of  a  scar,  but  clinical 
observation  has  shown  that  it  often  arises  in  scars  left  by  such 
slight  injuries,  that  it  is  very  reasonable  to  believe  that  the  sup- 
posed spontaneous  keloid  arose  in  scars  whose  existence  had 
been  forgotten. 

Taylor*  has  described  a  very  extreme  example  of  keloid 
which  came  under  his  observation  in  a  coloured  woman 
twenty-three  years  of  age.  (Fig.  44.)  When  ten  years  old 
this  patient  suffered  many  hardships,  and  was  the  drudge  or 
the  family ;  she  was  required  to  go  into  the  woods  for  fuel,  and, 
having  no  clothes  above  the  waist,  was  frequently  torn  m  linear 
stripes  by  the  bushes  and  briars.  In  the  scars  resulting  from 
these  injuries  the  keloid  masses  shown  in  the  figure  de- 
veloped. The  growth  on  the  pinna  formed  around  a  hole  made 
for  an  ear-ring.  This  tumour  has  been  three  times  removed, 
and  has  re-formed  after  each  operation. 

*  Xew  York  Med.  Journal,  Jan.  7,  1893. 


59 


CHAPTER    VI. 

MYXOMATA. 

A  myxoma  is  a  tumour  composed  of  mucous  tissue  identical 
v/ith  that  which  surrounds  the  vessels  of  the  umbilical  cord. 

This  genus  contains  three  species  : — 

(1)  Nasal  and  aural  polypi ;  (2)  Cutaneous  myxomata  ;  (3) 
Neuro-myxomata. 

Myxomatous  tissue  is  often  the  result  of  degenerative 
changes  in  cartilage,  muscle,  sarcomatous  and  fibrous  tissues. 
Some  writers  hold  the  opinion  that  giving  a  myxoma  the 
rank  even  of  a  species  is  not  justifiable. 

1.  Nasal  Polypus. — This  species  is  the  purest  form  of 
myxoma ;  it  grows  from  the  mucous  membrane  covering  the 
turbinal  bones,  and  occasionally  from  the  mucous  Iming  of 
the  frontal  sinuses,  and  rarely  from  the  mucous  membrane  of  the 
antrum.  Nasal  polypi — for  they  usually  occur  m  multiples — 
hang  in  the  nasal  fossse  as  soft  gelatinous  tumours  of  a  greyish- 
yellow  colour.  Each  polypus  may  consist  of  a  single  lobule 
attached  to  the  mucous  membrane  of  a  turbinal  bone  by  a 
narrow  peduncle.  Not  infrequently  a  polypus  may  be 
racemose,  a  number  of  lobules  being  attached  by  a  common 
stalk.  The  number  of  polypi  varies  greatly  ;  exceptionally 
only  one  is  present ;  often  six  or  more  will  be  found.  They 
may  be  confined  to  one  nasal  fossa ;  more  often  both  fossae 
contain  polypi.  When  they  are  very  numerous  and  not  inter- 
fered with,  the  nasal  passages  are  expanded,  and  the  polypi 
are  visible  at  the  anterior  nares,  or  project  through  the  pos- 
terior nares,  and  block  up  the  naso-pharynx,  forming  pendulous 
masses  behind  the  soft  palate.  Sometimes  a  polypus  will 
extend  so  low  as  to  reach  the  level  of  the  aryteno-ej)iglottic 
folds.  In  the  rare  instances  of  myxomata  occupying  the 
frontal  sinus,  they  cause  a  peculiar  bulging  at  the  inner  angle 
of  the  orbit  like  that  produced  by  distension  of  this  sinus 
with  fluid. 

A   nasal   myxoma   has   an   external    capsule    of  mucous 


60  CONNECTIVE     TISSUE     TUMOURS. 

membrane  covered  with  epithelium,  which  may  be  of  the 
cohimnar  (cihated)  or  stratified  variety.  Sometimes  two 
varieties  will  be  detected  on  the  same  tumour.  Stratified 
epithelium  is  common  on  the  exposed  parts  of  a  polypus. 
The  bulk  of  the  tumour  is  composed  of  myxomatous  tissue 
traversed  by  numerous  blood-vessels.  On  microscopical 
examination  it  resembles  very  oedematous  connective  tissue ; 
the  cells  possess  long  slender  processes  which  interlace  with 
those  of  adjacent  cells. 

Nasal  myxomata  are  rare  before  puberty,  and,  though 
most  frequently  met  with  in  young  adults,  are  by  no  means 
rare  in  individuals  of  middle  age. 

Aural  Polypus. — Small  myxomata  grow  from  the  mucous 
membrane  of  the  tympanum.,  and  constitute  one  variety  of 
aural  polypus ;  when  large  enough  to  block  up  the 
tympanic  cavity  or  occlude  the  external  auditory  meatus,  they 
produce  deafness.  At  birth  the  tympanum  is  filled  with 
delicate  foetal  connective  tissue  and  the  ear-bones  are  em- 
bedded in  it.  As  pulmonary  respiration  becomes  established 
this  tissue  slowly  disappears,  and  air  from  the  pharynx 
gradually  gains  access  to  the  tympanum  by  way  of  the 
Eustachian  tube.  Jacobson*  has  suggested  that  aural 
myxomata  may  in  some  instances  arise  from  vestiges  of  this 
connective  tissue. 

2.  Cutaneous  Myxomata. — These  occur  either  as  sessile  or 
pedunculated  tumours.  They  are  by  no  means  common. 
Some  of  the  most  typical  cases  that  have  come  under  my 
observation  presented  themselves  as  sessile  tumours  in  the 
loin,  but  not  extending  beyond  the  deep  fascia.  When 
divided,  the  surface  of  a  pure  myxoma  resembles  a  mass  of 
transparent  trembling  jelly ;  a  viscid  fluid,  sometimes  of  a 
pale  straw  colour,  drains  from  it. 

Pedunculated  myxomata  are  most  frequent  in  the  neigh- 
bourhood of  the  perineum  and  labia.  In  young  individuals 
they  possess  a  regular,  usually  oval,  outline.  Later  in  life,  as 
the  fluid  parts  absorb,  they  assume  the  lobulated  appearance 
shown  in  Fig.  45. 

Sessile  myxomata  are  very  prone  to  recur  after  removal ; 
in  some  instances  it  is  very  probable  that  they  are  sarcomata 

*  Guy's  Hospital  Reports,  1882,  vol.  xli.  p.  217. 


MYXOMATA. 


61 


which  have  undergone  myxomatous  degeneration.  Such  a 
tumour  is  sometimes  called  sarcoma  myxoiiiatodes. 

The  pedunculated  variety  approximates  in  structure  very 
closely  to  the  pendulous  cutaneous  folds  characteristic  of 
molluscum  fibrosum. 

3. .  Neuro-Myxomata  are  described  with  neuromata  in 
chap.  xvi. 

Myxomatous  Disease  of  the  Chorion. — It  is  usual  in  works 
on  tumours  to  describe  this  interesting  condition  (the  hydatid 


Fig.  45. —  Pedunculated  myxoma  from  the  labium  of  a  woman  fifty  years  old  :  it 
had  existed  many  years. 

mole  of  midwifery) ;  but  as  it  does  not  in  any  strictness 
belong  to  tumours,  it  will  not  be  considered  further  in  this 
treatise. 

Treatment. — Myxomata,  like  tumours  in  general,  should 
be  removed  whenever  their  position  and  relations  to  surround- 
ing structures  permit.  In  the  case  of  nasal  polypi  this  plan 
of  treatment  is  invariably  adopted,  and  there  are  several 
methods  of  effecting  their  removal,  such  as  snaring  them  with 
small  wire  snares,  or  detaching  them  with  a  galvano-cautery, 


62  CONNECTIVE     TTSHUE     TUMOURS. 

or  avulsion  with  forceps.  When  the  polypi  are  confined  to 
the  lowest  and  middle  turbinals  they  are  easily  and  completely 
torn  away,  but  when  they  spring  from  the  highest  turbinal  or 
occupy  the  ethmoid  cells  and  frontal  sinus,  it  is  a  difficult 
matter  to  eradicate  them  thoroughly. 

Pedunculated  myxomata,  of  the  kind  represented  in  Fig.  45, 
are  easily  removed  ;  they  never  recur. 


63 


CHAPTER    yil. 

GLIOMATA. 


A  glioma  is  a  tumour  composed  of  delicate  comiective  tissue 
identical  with  the  variety  known  as  neuroglia.  This  genus 
consists  of  a  single  species — glioma — which  bears  the  same 
relation  to  the  central  nervous  system  that  a  plexiform 
neuroma  bears  to  the  peripheral  nerves. 

Gliomata  occur  only  in  the  central  nervous  system.  A 
tissue  very  similar  to  neuroglia  forms  the  sustentacular  frame- 
work of  the  retina.  This  is  frequently  the  seat  of  sarcomata, 
which  are  often  termed  retinal  gliomata.     (See  page  87.) 

Gliomata  of  the  Brain. — In  the  brain  a  glioma  occurs  as  a 
tumour  imperfectly  demarcated  from  the  surrounding  tissue. 
It  may  appear  as  a  translucent  swelling  of  the  consistence 
of  vitreous  humour,  or  it  may  be  as  firm  as  the  tissue  of 
the  pons.  As  a  rule,  a  glioma  is  of  the  same  firmness  as  the 
cerebral  cortex. 

Structurally,  gliomata  consist  of  cells,  containing  one 
or  more  .nuclei,  furnished  with  delicate  ramifying  processes, 
mixed  with  fibrous  tissue.  The  proportion  of  cells  to  the 
fibrous  tissue  varies  greatly ;  sometimes  one  set  of  ele- 
ments preponderates,  sometimes  the  other.  These  tumours 
are  often  very  vascular,  the  vessels  being  irregularly 
dilated  and  occasionally  sacculated.  The  number  of  blood- 
vessels in  some  specimens  is  so  great  that  the  tumours  are 
described  as  angeiomata  or  angeio-sarcomata. 

As  a  rule,  gliomata  are  solitary,  and  they  do  not  give  rise 
to  secondary  deposits.  In  certain  situations  they  rather 
resemble  diffuse  overgrowths  than  tumours.  Virchow  pointed 
out  that  when  a  glioma  is  situated  near  the  surface  of  the 
cortex  it  will  appear  like  a  colossal  convolution.  Should  it 
grow  in  the  tissue  of  an  optic  thalamus  it  would  cause  the 
thalamus  to  bulge  into  the  third  ventricle  as  though  over- 
grown, and  a  glioma  of  the  occipital  lobe  will  project  into  the 
descending  cornu  like  an  additional  thalamus.  The  best 
illustration  of  this  indefiniteness  so  characteristic  of  a  glioma 


64  GONNEGTIVE     TISSUE     TUMOURS. 

comes  out  very  strikingly  Avlien  the  pons  is  occupied  by  this 
form  of  tumour. 

Gliomata  occasionally  occur  in  the  pons,  and  form  tumours 
of  considerable  size.  Sometimes  they  are  confined  to  one  side, 
and  extend  into  the  adjacent  cerebellar  crura.  In  a  case  de- 
scribed by  Cayley,*  which  occurred  in  a  child  two  years  of  age, 
a  glioma  as  large  as  a  walnut  occupied  the  right  half  of  the 
pons  and  extended  along  the  superior  cerebellar  peduncle  of 
that  side,  reaching  as  far  forward  as  the  corpora  quadrigeinina. 
The  gliomatous  mass  formed  a  prominence  on  the  correspond- 
ing half  of  the  floor  of  the  fourth  ventricle,  and  obstructed  the 
Sylvian  aqueduct. 

In  some  cases  both  sides  of  the  pons  are  involved,  and  the 
overgrowth  of  neuroglia  extends  forwards  into  the  cerebral 
crura  and  the  cerebellar  peduncles,  and  involves  the  corpora 
quadrigemina.  In  a  few  it  extends  downwards  into  the 
medulla,  and  may  even  involve  the  cervical  portion  of  the  cord, 
as  in  a  specimen  described  by  Whipham.f 

Sometimes  the  gliomatous  tissue  is  so  abundant  as  to  pro- 
duce an  enlargement  of  the  pons  and  cerebral  peduncles,  as 
represented  in  Fig.  46.  The  appearance  of  such  brains  is  very 
peculiar ;  the  basilar  artery  and  its  branches  appear  as  though 
sunk  in  deep  furrows,  which  cause  the  parts  to  resemble  "  a 
soft  package  tightly  corded"  (Dickinson).  Such  cases  are 
rare,  and  in  nearly  all  instances  the  patients  have  been  under 
twelve  years  of  age.  Thus  the  case  recorded  by  Percy  KiddJ 
occurred  in  a  girl  six  and  a-half  years  old.  Gee's  §  patient  was 
a  boy  of  nine  years.  In  two  cases  described  by  Angel  Money,  || 
one  was  a  boy  of  eleven  years,  and  the  other  a  girl  of  six  and 
a-half  years.  GoodhartH  has  described  a  specimen  from  a  boy 
aged  nine  years ;  Schulz**  has  observed  one  in  a  man  of  thirty- 
two  years.  The  relations  of  a  glioma  to  the  surrounding  tissues 
are  best  seen  in  recent  specimens.     On  examination  soon  after 

*  Trans.  Path..  Soc,  vol.  xvi.,  p.  23. 
t  Trans.  Path.  Soc,  vol.  xxxii.,  p.  8. 
J  St.  Barth.  Hosp.  Rep.,  vol.  xiii.,  p.  272. 
§  St.  Barth.  Hosp.  Rep.,  vol.  xvii.,  p.  285. 
II  Med.-Chir.  Trans.,  vol.  Ixvi.,  p.  283. 
^  Trans.  Path.  Soc.,  vol.  xxxvii.,  p.  14. 
**  Neurologisches   Centralblatt,    1883,    s.    5.      This   paper   contains   several 
references. 


GLIOMATA. 


65 


death  the  diseased  parts  are  abnormally  large,  and  on  section 
exhibit  a  characteristic  pale  blue  colour;  m  thin  sections  the 
tissue  has  a  delicate  translucent  appearance.  The  tumour 
itself  is  very  soft,  and  imparts  to  the  fingers  a  sensation  like 
fluctuation.  When  the  parts  are  immersed  in  alcohol  the 
tissue  becomes  firm,  opaque,  and  white;  under  these  conditions 


Fig.  46.— Bilateral  glioniatous  enlargement  of  the  pons  and  crura  cerebri.     (Angel  Money.) 


it   is   particularly   difficult   to   determine    the   limits   of  the 
tumour. 

Gliomata  of  the  Spinal  Cord. — A  glioma  in  the  spinal  cord 
is  a  very  rare  tumour,  and,  judging  from  the  scanty  records,  it 
would  appear  that  a  glioma  in  the  brain  is  twenty  times  more 
frequent  than  in  the  cord.  The  tumour  is  imperfectly  demar- 
cated from  the  nervous  tissue,  and  often  causes  a  general 
enlargement  of  the  cord,  producing  an  effect  upon  it  like 
the   glioniatous    disease    of    the  pons,   crura,   and    medulla 

F 


66  CONNECTIVE    TISSUE    TUMOURS. 

depicted  in  Fig.  46.  Keisinger*  collected  and  epitomised  the 
records  of  nineteen  cases  of  glioma  of  the  spinal  cord,  and  adds 
a  fidl  description  of  a  case  which  he  observed ;  the  report  is 
accompanied  by  an  account  of  the  morbid  anatomy  of  the 
parts  by  Prof.  Marchand. 

The  disease  may  attack  any  part  of  the  cord,  but  is  most 
frequent  in  the  cervical  enlargement.  In  a  few  instances  the 
tumour  was  seated  in  the  lumbar  region.  It  appears  most  fre- 
quently between  the  seventeenth  and  thirtieth  years,  but  it  has 
been  observed  as  late  as  fifty.  Sharkeyf  has  published  an 
interesting  account  of  a  spinal  glioma  which  occurred  in  a  man 
fifty  years  old,  and  he  uses  it  to  demonstrate  the  clinical  fact 

that  when  a  tumour  arises  within 
-Grey  matter.  ^YiQ  cord,  as  gliomata  always  do, 
-Tumour.  [i   disturbs   its   functions  from 

-Grey matter,     the    Commencement  ;    but,    as 
the  nerve  substance  appears  to 

Fig.  47.— Spinal  cord,  in  transverse  .section,  |         placti/i     Q-nrl     to    flllowfl    CTOOfl 

from    a  case   of  glioma.      The   expanded  ^tC    eidSUC,  anu    lO    aUOW    a   gOOU 

nerve  tissue  forms  a    rim,    or    capsule,  plpol   rtf  crrqrlnQl  cifvpf r-Viincc  witli- 

around  the  tumour     (After  Sharkey.)  ^Leai  01  giaClUai  StietCnmg  WlUl 

out  serious  interference  Avith  its 
functions,  a  tumour  may  continue  to  grow  for  a  long  time 
before  it  produces  striking  pathological  phenomena  (Fig.  47). 
When  a  tumour  grows  in  the  spinal  canal  outside  the  cord  it 
may  produce  but  few  symptoms  until  it  presses  the  cord 
against  the  resisting  walls  of  the  canal ;  after  this  has  taken 
place  the  course  of  the  disease  is  naturally  very  rapid,  as 
the  cord  is  quickly  flattened  by  the  constantly  increasing 
demands  for  growing-space  which  are  made  by  the  tumour. 

The  peculiar  relation  of  the  gliomatous  tissue  to  the  nerve 
tissue  of  the  cord  precludes  any  surgical  interference. 

*  Virchow's  "Archiv,"  xcviii.  369. 
f  Gulstonian  Lectures,  1886. 


67 


CHAPTER     VIII. 

SARCOMATA. 

The  histological  characters  of  sarcomata  are  those  of  immature 
connective  tissue,  in  which  cells  preponderate  over  the  inter- 
cellular substance.  Clinically,  sarcomata  are  distinguished 
from  the  preceding  genera  of  tumours  in  that  they  rarely  pos- 
sess capsules,  infiltrate  the  surrounding  tissues  and  are  prone 
to  disseminate ;  their  infiltrating  propensities  render  complete 
removal  a  matter  of  difiiculty,  hence  sarcomata  are  liable  to 
recur.  Such  characters  constitute  malignancy.  Sarcomata 
are  arranged  in  species  according  to  the  shape  and  disposition 
of  the  cells. 

1.  Round-celled  sarcoma. 

2.  Lympho-sarcoma. 

3.  Spindle-celled  sarcoma. 

4.  Myeloid  sarcoma. 

5.  Alveolar  sarcoma. 
■6.  Melano-sarcoma. 

The  round  and  spindle-celled  species  present  varieties 
which  will  be  particularised  when  each  species  is  separately 
considered. 

1.  Round-celled  Sarcomata. — This  species  is  of  very  simple 
construction,  and  consists  of  round  cells  with  very  little  inter- 
cellular substance.  The  cells  contain  a  large  round  vesicular 
nucleus  and  a  small  proportion  of  protoplasm  ;  the  nuclei  are 
always  conspicuous  objects  in  stained  sections.  Blood-vessels 
are  abundant,  often  appearing  as  mere  channels  between  the 
cells.  Lymphatics  are  absent.  Round-celled  sarcomata  grow 
very  rapidly,  infiltrate  surrounding  tissues,  recur  quickly  after 
removal,  and  give  rise  to  secondary  deposits  especially  in  the 
lungs. 

There  is  a  variety,  known  as  the  large  round-celled  sarcoma, 
in  which  the  cells  are  of  unequal  size ;  some  of  them  contain 
two  or  more  nuclei;  a  few  are  multinuclear,  and  resemble 
myeloid  cells. 

The  round-celled  sarcoma  is  the  most  generalised  tumour 


68 


CONNECTIVE    TISSUE    TUMOURS. 


that  affects  the  human  body ;  it  may  occur  in  any  tissue, 
bone,  brain,  nmscle,  spinal  cord,  ovary,  or  testis,  and  even  in 
the  dehcate  sustentacular  framework  of  the  retina.  It  attacks 
the  body  at  all  periods  of  life,  from  the  foetus  in  viero  and  the 


Fig.  48.— Microscopical  appearance  of  a  lymplio-sarcoma  from  the  mediastinum. 

child  just  born  up  to  the  extreme  limits  of  age.      Among 
vertebrate  animals  it  is  almost  ubiquitous. 

2.  Lympho-Sarcomata  consist  of  cells  identical  with  those 
of  round-celled   sarcomata,  but   the   cells   are   contained   in 


C3     ^^^r^^-,^SS=  r~ 


PC3 

^=3  C 


Fig.  49. — Small  spindle-celled  sarcoma  from  a  metacarpal  bone. 

delicate  meshes  :  the  tissue  resembles  that  of  lymphatic  glands 
(Fig.  48),  hence  the  origin  of  the  term  lympho-sarcoma.  These 
tumours  must  not  be  confounded  with  simple  (irritative) 
enlargement  of  lymphatic  glands,  nor  with  the  general  over- 
growth of  lymph-adenoid  tissue  associated  with  leukaemia  or 
lymphadenoma  (Hodgkin's  disease). 

3.  Spindle-celled   Sarcomata. — The  cells  of  the  species 


SARCOMATA.  69 

classed  under  this  head  vary  considerably  in  size,  but  tliey 
agree  in  the  circumstance  that  they  are  oat-shaped  (Fig.  49) 
or  fusiform.-  The  cells  have  a  tendency  to  run  in  bundles, 
which  take  different  directions,  so  that  in  sections  of  the 
growth  seen  under  the  microscope  some  cells  will  be  cut  in 
the  direction  of  their  length  and  others  at  right  angles. 
This  must  be  borne  in  mind,  or  an  incorrect  opinion  will  be 
formed  as  to  the  nature  of  the  tumour. 


/ 


/ 


Fig.  50. — Cells  from  a  splnclle-eelleil  sarcoma  of  the  neck  of  the  uterus.     Some  of  the 
cells  jireseut  a  cross-striation.     {AfUr  Periiice.) 

The  following  facts  will  afford  some  idea  as  to  the  degree 
of  variation  in  size  of  the  cells  of  spindle-celled  sarcomata. 
In  some  of  the  tumours  the  cells  are  so  thin  and  slender,  and 
contain  so  little  protoplasm  that  they  seem ,  to  consist  only  of 
a  nucleus  and  cell  processes.  It  is  difficult  to  distinguish 
such  cells  from  those  of  moderately  firm  fibrous  tissue. 

In  other  specimens  the  ceUs  are  large,  beautifully  fusiform, 
and  rich  in  protoplasm.  Such  cells  give  rise  to  considerable 
difficulty  to  the  morbid  anatomist,  and  he  often  feels  in- 
competent  to   decide    between    them   and   those   of   young 


70  CONNECTIVE    TISSUE    TUMOUIiS. 

imstriped  muscle-fibre.  The  complexity  of  such  tumours  is 
further  increased  by  the  fact  that  occasionally  these  long 
spindle-cells  are  transversely  striated  like  voluntary  muscle 
fibre.  (Fig.  50.)  This  variety  of  sarcoma  is  known  as 
myo-sarcom a  (rhabdomy om a). 

Another  peculiarity  of  spindle-celled  sarcomata  is  the 
frequent  presence  of  tracts  of  immature  hyaline  cartilage  ; 
indeed  in  many  instances  this  tissue  constitutes  so  large  a 
proportion  of  the  tumours  that  they  are  described  as  chondro- 
mata ;  the  cartilage  is  sometimes  calcified  and  even  ossified. 
It  may  seem  strange  to  associate  tumours  containing  striped 
cells  and  cartilage  with  sarcomata,  but  the  correctness  of  the 
classification  is  demonstrated  by  the  fact  that  such  tumours 
are  apt  to  recur  after  removal,  and  in  some  of  the  cases  in 
which  the  primary  and  recurrent  tumours  have  been  carefully 
examined,  the  primary  tumour  has  contained  cartilage,  or 
muscle,  whilst  the  recurrent  mass  has  shown  no  evidence  of 
these  tissues,  but  has  conformed  to  the  structure  of  a  pure 
spindle-celled  or  a  round-celled  sarcoma.  In  order,  there- 
fore, to  indicate  the  nature  of  such  composite  sarcomata  they 
will  be  referred  to  as  myo-sarcomafa  (rhabdomyomata)  and 
chondro-sarcomata.  Spindle-celled  sarcomata  often  contain 
round  and  even  multinuclear  cells. 

In  slow-growing  spindle-ceUed  sarcomata  the  cells  some- 
times become  converted  into  fibrous  tissue  ;  such  tumours 
are  often  termed  fibro-sarcomata  or  fibrifying  sarcomata. 

4.  Myeloid  Sarcomata. — This  species  is  composed  of  tissue 
histologically  resembling  the  red  marrow  of  young  bone. 
Myeloid  sarcomata  usually  occur  in  the  long  bones  and  are  of 
a  deep  red  or  maroon  colour,  and,  when  fresh,  the  cut  surface 
looks  like  a  piece  of  liver.  The  tissue  contains  large  numbers 
of  multinuclear  cells  embedded  in  a  matrix  of  spindle  or 
round  cells.  Many  central  tumours  of  bone  contain  multi- 
nuclear cells,  but  it  is  only  when  these  large  cells  are  present 
in  such  quantity  as  to  make  up  a  large  part  of  the  tumours 
that  they  should  be  classed  as  myeloid  sarcomata.     (Fig.  51.) 

5.  Alveolar  Sarcomata. — This  is  a  peculiar  species  of 
tumour  in  which  the  cells,  contrary  to  the  rule  of  sarcomata, 
generally  assume  an  alveolar  arrangement  which  mimics  very 
strongly  the  disposition  of  cells  characteristic  of  cancer.     In 


SARCOMATA.  71 

carefully  prepared  sections  such  tumours  rarely  cause  diffi- 
culty because  the  cells  are  usually  of  large  size,  and  even 
when  they  resemble  epithelium  it  is  possible  to  distinguish 
a  delicate  reticulum  between  the  individual  cells,  a  condition 
never  found  in  cancer. 

Alveolar  sarcomata  have  occasionally  been  described  as 
growing  in  connection  with  bone,  but  their  common  situation 
is  the  skin,  especially  in  relation  with  those  congenital  defects 


\ 


'?--$^^xQfc;^5::r^ 


I  ( 


A 


U   s 

'>':\ 


Fig.  51. — Myeloid  sarcoma  frou  the  acromial  end  of  the  clavicle. 

known  as  hairy  and  pigmented  moles.  The  peculiarities  of 
this  species  will  be  more  fully  considered  in  the  chapter 
devoted  to  melano-sarcomata. 

6.  Melano-sarcomata.  —  Structurally  this  species  may 
be  composed  of  round  or  spindle  cells,  and  they  may  some- 
times be  arranged  in  alveoli ;  the  distinguishing  feature 
is  the  presence  in  the  cells  and  in  the  intercellular 
substance  of  a  variable  quantity  of  black  pigment. 

The  Blood-Svypply  of  Sarcomata. — The  vascularity  of 
sarcomata  varies  greatly  ;  in  all,  the  circulation  is  mainly 
capillary.  In  the  small  round-celled  sarcomata  the  vessels 
are  so  numerous  as  to  cause  a  distinct  pulsation  and  a  bruit, 


72  CONNECTIVE    TISSUE    TUMOITRS. 

whilst  in  tlie  slow-growing  spindle-celled  varieties — especially 
those  undergoing  chonclrification  —  the  vessels  are  not 
numerous,  and  the  tumours  on  section  are  of  a  white  colour. 
It  has  already  been  pointed  out,  in  describing  the  minute 
structure  of  sarcomata,  that  the  walls  of  the  vessels  are  very 
thin,  and  are  often  so  attenuated  as  to  resemble  channels 
between  the  cells.  This  explains  the  frequency  of  haemorrhage 
within  the  soft  and  rapidly  growing  varieties.  Eepeated 
extravasations  of  blood  will  sometimes  convert  these  tumours 
into  cysts  containing  blood  intermixed  with  sarcomatous  cells. 
Tumours  transformed  in  this  way  were  formerly  described  as 
malignant  blood-cysts. 

Although  the  vessels  in  a  sarcoma  are,  in  the  main, 
capillaries,  nevertheless  the  arteries  supplying  the  tumour 
may  be  very  large  and  numerous.  When  a  sarcoma  grows 
from  the  distal  end  of  the  femur  and  attains  a  large  size, 
arteries  supplying  it  from  neighbouring  muscular,  periosteal, 
and  articular  trunks  become  important  branches,  and  in  such 
circumstances  an  incision  into  the  tumour  will  be  attended 
with  alarming  hsemorrhage.  When  attempts  are  made  to 
dissect  out  such  a  tumour  from  the  limb  instead  of  adopting 
more  radical  measures,  such  as  amputation,  these  enlarged 
vessels  must  not  be  forgotten,  or  they  will  intrude  themselves 
upon  the  surgeon  in  a  very  unmistakable  manner.  Arteries 
which,  under  ordinary  conditions,  are  almost  inappreciable, 
will,  when  nourishing  a  sarcoma,  attain  the  dimensions  of  the 
radial  or  even  larger  trunks. 

Dissemination. — Sarcomata  are  liable  to  reproduce  them- 
selves in  distant  organs,  a  phenomenon  frequently  referred  to 
as  metastasis.  This  dissemination  takes  place  mainly  through 
the  veins  because,  as  has  already  been  mentioned,  sarcomata 
are  devoid  of  lymphatics.  The  most  common  organ  in  which 
to  find  secondary  sarcomata  is  the  lung,  unless  the  primary 
growth  is  situated  in  the  territory  of  the  portal  circulation, 
then  they  will  be  found  in  the  liver.  In  very  malignant 
sarcomata,  especially  the  small  round-celled  species,  secondary 
deposits  may  form  in  an}^  organ  of  the  body.  Secondary 
nodules  are  always  identical  in  structure  with  the  primary 
tumour. 

The  Infiltrating  Properties  of  Sarcomata. — The  tendency 


SARCOMATA.  73 

to  extensively  infiltrate  the  planes  of  connective  tissue  adjacent 
to  the  tumour  is  not  peculiar  to  sarcomata,  for  it  is  observed 
in  carcinomata.  This  property,  so  far  as  sarcomata  are 
concerned, ,  comes  out  in  a  marked  manner  in  the  case  of 
the  voluntary  muscles. 

Sarcomata  occur  in  voluntary  muscles  under  three  con- 
ditions : — 

1,  Primary  tumours  ;  2,  Infiltrations  from  adjacent 
tumours ;  3,  secondary  deposits. 

Primary  sarcomata  of  muscles  are  very  rare;  they  may  be 
of  the  round-celled  or  spindle-celled  species.  For  a  time  at 
least  the  tumour  is  limited  by  the  sheath  of  the  affected 
muscle.  At  first  the  disease  appears  localised  to  a  particular 
spot  of  the  muscle,  but  it  graduall}^  extends  until  the  whole 
belly  of  the  muscle  is  involved,  and  becomes  transformed  into 
an  indurated  mass.  On  section  the  muscle-tissue  appears 
replaced  by  hard,  tough  material  of  a  pale  grey  colour.  When 
sections  are  examined  under  the  microscope  the  appearance  is 
very  striking,  for  each  fasciculus  is  isolated  from  its  neighbour 
by  collections  of  cells  (usually  round  cells)  characteristic  of  the 
sarcoma. 

Primary  sarcomata  have  been  observed  in  the  following 
muscles  : — Pectoralis  major,  rectus  abdominis,  peroneus  longus, 
gracilis,  tensor  vaginse  femoris,  adductor  brevis,  sartorius, 
tibialis  anticus,  and  the  triceps. 

Injiltration  of  muscles  by  sarcomata  is  by  no  means  rare. 
For  instance,  when  a  retinal  sarcoma  protrudes  through  the 
posterior  part  of  the  sclerotic  and  invades  the  orbit,  it  some- 
times makes  its  way  into  the  sheaths  of  the  recti  and  converts 
them  into  masses  resembling  yellow  wax;  on  section  the  various 
fasciculi  will  be  found  isolated  by  the  cells  of  the  sarcoma. 

Periosteal  sarcomata  often  invade  muscles,  and  this  is 
easily  comprehended  when  the  intimate  relations  of  muscles  to 
periosteum  are  remembered.  Thus  in  Fig.  55  a  sarcoma 
springs  from  the  fibula  and  involves  the  origin  of  the  flexor 
longus  hallucis  and  the  peroneal  muscles.  In  a  similar  way 
I  have  seen  the  adductor  muscles  invaded  by  a  periosteal  sar- 
coma springing  from  the  upper  third  of  the  shaft  of  the  femur, 
and  it  doubtless  occurs  in  most  cases  in  which  sarcomata 
spring  from  bone  near  the  origin  or  insertion  of  muscles. 


74  CONNECTIVE    TISSUE    TUMOURS. 

Secondary  deposits  of  sarcomata  in  muscles  are  occasionally 
seen  where  there  is  wide  dissemination  of  the  disease  ;  in  such 
cases  scarcely  an  organ  escapes,  and  nodules  may  even  occur 
in  the  heart.  Care  must  be  exercised  not  to  confound  a 
syphilitic  gumma  in  a  muscle  with  a  sarcoma. 

The  Burrowing  Tendencies  of  Sarcomata. — All  tumours  in 
their  growth  tend  to  follow  the  lines  of  least  resistance,  and 
thus  enter  into  nooks  and  crannies  in  the  most  unexpected 
manner.  Every  surgeon  knows  how  a  sarcoma  of  the  maxilla 
will  send  processes  into  the  spheno-maxillary  fossa  and  creep 
through  the  foramen  rotundum,  to  appear  in  the  cranial  cavity. 
Sarcomata  springing  from  the  heads  of  the  ribs  or  processes 
of  the  vertebrae  have  been  known  to  extend  through  interverte- 
bral foramina  and  compress  the  cord,  giving  rise  to  fatal  para- 
plegia. In  one  case  the  tumour  has  been  removed,  and  the 
patient  recovered  motion  and  sensation.* 

This  burrowing  tendency  comes  out  very  strongly  in  the 
case  of  lympho-sarcomata  growing  in  the  mediastinum.  {See 
page  104.) 

It  is  also  remarkable  what  slender  barriers  will  serve  as 
checks  to  sarcomata.  For  example,  it  is  no  uncommon  condition 
to  find  one  of  these  tumours  springing  from  the  periosteum 
near  a  joint  extend  in  all  directions  and  envelop  the  sjmovial 
membrane,  yet  be  prevented  by  it  from  invading  the  joint. 

The  Relation  of  Sarcomata  to  Veins. — It  has  long  been 
recognised  that  when  sarcomata  become  disseminated  the 
secondary  tumours  occur  in  situations  which  indicate  that  the 
distribution  has  been  effected  by  means  of  the  veins.  Attention 
has  already  been  drawn  to  the  tendency  which  seems  inherent 
in  most  species  of  sarcomata  to  burrow  ;  this  tendency  comes 
out  in  a  striking  way  when  studied  in  connection  with  veins. 

Perhaps  the  simplest  form  occurs  in  the  eyeball.  When  a 
melanoma  arises  in  the  uveal  tract,  especially  when  the  tumour 
is  in  close  relation  with  the  choroid,  it  remains  for  a  period  re- 
stricted to  the  interior  of  the  globe,  until  it  produces  such 
changes  in  the  intra-ocular  tension  that  the  cornea  sloughs  and 
the  growth  protrudes  externally.  In  many  of  these  specimens, 
if  the  sclerotic  be  carefully  examined  in  the  situations  where 

*  Davies-CoUey,  Trans.  Clin.  Soc. ,  vol.  xxv.  163. 


SARCOMATA. 


75 


the  venae  vorticos^e  pierce  it,  small  nodules  of  the  tumour  will 
he  detected  projecting  through  these  openings,  having  made 
their  way  out  by  burrowing  in  the  sheaths,  and,  in  some 
cases,  actually  travelling  along  the  lumina  of  the  veins. 


Inferior  vena  cavf 


Intravenous  process 
of  the  sarcoma. 


Glands    infected    by 
sarcoma. 


( I-  J 1  — ^v A  sarcoma  springing; 

from  tlie  ilium. 


52. — Periosteal  sarcoma  of  tlie  ilium  invading  the  inferior  vena  cava.     {M^iseum, 
St.  BartJiolomew's  Hospital.) 


The  relations  of  sarcomata  to  veins  come  out  strongly  when 
these  tumours  affect  bones.  In  some  examples  of  periosteal 
sarcomata  the  medulla  is  invaded  by  processes  of  the  tumour 
making  their  way  along  the  veins  traversing  the  Haversian 
canals.  The  converse  of  this  is  also  true,  for  a  central  sar- 
coma will  sometimes  implicate  the  periosteum  by  way  of  the 
Haversian  canals. 

It  is  well  established  that  most  examples  of  central  sar- 


76  CONNECTIVE    TISSUE    TUMOUBH. 

comata  occur  near  the  joint  ends  of  bones,  and  yet  it  is  excep- 
tional to  find  the  joints  invaded.  When  joint  invasion  happens, 
it  occurs  late  in  the  course  of  the  disease,  and  then,  in  most 
cases,  the  tumour  creeps  in  through  the  synovial  membrane. 
This  comparative  immunity  of  joints  is  usually  attributed  to 
the  articular  cartilage  acting  as  neutral  tissue;  but  it  appears 
rather  to  be  due  to  the  fact  that  the  cartilas^e,  unlike  the  com- 
pact  tissue  of  bone,  is  not  traversed  by  a  multitude  of  narrow 
venous  channels.  Extraordinary  examples  of  the  invasion  of 
veins  b}^  sarcomata  occur  in  the  abdomen.  In  cases  of  renal 
sarcomata  processes  of  tumour  will  find  their  way  into  the  renal 
vein,  and  thus  gain  the  inferior  vena  cava.  Periosteal  sarcomata 
of  the  pelvic  surface  of  the  ilium  are  very  liable  to  infiltrate 
the  iliac  veins  and  extend  into  the  vena  cava.     (Fig.  52). 

This  specimen  illustrates  very  well  the  general  relation  of 
an  intravenous  outrunner  from  a  sarcoma;  the  process  lies  freely 
in  the  lumen  of  the  vein,  its  apex  is  smooth  and  rounded,  and 
there  are  no  lateral  adhesions  save  in  the  situations  where  the 
main  mass  of  the  tumour  infiltrates  the  wall  of  the  vein.  The 
portion  of  the  sarcoma  situated  within  the  vein  is,  as  would  be 
expected,  structurall}^  identical  with  the  main  mass  of  the 
tumour,  and  has  its  own  blood-vessels,  Avhich  are  continuous 
with  those  of  the  sarcoma. 

Such  a  large  invasion  of  a  venous  trunk  as  is  represented 
in  Fig.  52  is  unusual,  but  it  is  by  no  means  rare  to  find  a  small 
portion  of  a  sarconia  projecting  into  the  lumen  of  a  vein  to  the 
extent,  perhaps,  of  2,  3,  or  4  cm. 

When  processes  from  a  sarcoma  project  into  a  vein,  the 
circulating  blood  is  apt  to  detach  large  fragments,  and  these 
become  dangerous  emboli.  Thus  Osier*  has  recorded  an 
example  of  renal  sarcoma  with  intravenous  processes  in  which 
so  large  a  piece  was  detached,  carried  forward,  and  arrested 
at  the  right  auriculo-ventricular  orifice  that  it  speedily  killed 
the  patient,  a  child  three  years  old. 

The  mere  presence  of  a  sarcomatous  outrunner  in  a  vein 
does  not  necessarily  imply  dissemination  of  the  sarcoma,  for 
very  large  intravenous  processes  may  exist,  and  the  lungs  be 
free  from  any  gross  lesion  of  a  sarcomatous  nature.     On  the 

*  Jourii.  Anat.  and  Fhijs.,  vol.  xiv.,  p.  230. 


SARCOMATA.  77 

other  hand,  a  very  small  invasion  may  lead  to  extensive  infec- 
tion of  the  lungs,  especially  if  the  protruding  surface  of  the 
tumour  be  eroded  by  the  blood  current. 

Dr.  Pitt*  has  described  a  case  in  which  a  man  with  sarcoma 
of  the  thyroid  gland  died  suddenly.  At  the  post-mortem 
examination  the  cavities  on  the  right  side  of  the  heart  con- 
tained fragments  of  growth  embedded  in  clot ;  on  dissection  it 
was  ascertained  that  the  sarcoma  had  ulcerated  into  the 
internal  jugular  vein. 

When  a  vein  is  invaded  by  a  sarcoma,  and  discharges  of 
emboli  frequently  occur,  they  easily  traverse,  when  small,  the 
right  auricle  and  ventricle,  but  are  too  large  to  pass  through 
the  pulmonary  capillaries ;  hence  the  small  vessels  in  the  limgs 
act  as  filters,  and  these  arrested  particles  become  secondary 
foci,  and  may  attain  the  size  of  cob-nuts. 

It  is  possible  that  sarcomata  may  originate  in  the  walls  of 
a  vein  and  extend  along  its  lumen.  Griftithst  has  recorded  a 
case  of  this  kind  in  connection  with  the  internal  jugular  vein. 

Secondary  Changes. — Sarcomata  are  very  prone  to  degene- 
rative changes;  for  instance,  htemorrhage  is  very  apt  to  take 
place  in  those  Avhich  grow  quickly,  producing  spurious  cysts. 
The  tissues  of  the  tumour  are  apt  to  liquefy,  and  mj-xomatous 
changes  are  very  common.  Calcification  occurs  in  those  Avhich 
grow  slowly,  especially  if  connected  with  bone.  When  sarco- 
mata grow  rapidly  and  involve  the  skin,  ulceration  is  very 
prone  to  occur,  and  leads  to  profuse  and  oft-repeated  hsemor- 
rhages,  which  not  only  exhaust  the  patient,  but  in  many 
cases  induce  death. 

Occasionally  considerable  portions  of  a  sarcoma  will  necrose ; 
this  is  more  apt  to  occur  in  very  large  tumours.  In  such  cases 
a  large  spurious  cyst  forms  in  the  sarcoma,  and  on  cutting  into 
it  the  fluid  escapes,  with  large  irregular  pieces  of  the  tumour, 
which  are  generally  of  a  greyish-white  colour.  When  necrosis 
occurs  extensively  in  a  large  sarcoma  it  will  sometimes  check 
its  course  in  a  very  marked  manner. 

*  Trans.  Path.  Soc,  vol.  xxxviii.  398.  See  Paget's  classical  case,  Med.-Chir. 
Trans.,  vol.  xxxviii.  247. 

t  Trans.  Path.  Soc,  vol.  xxxix.  311. 


78 


CHAPTER  IX. 

SARCOMATA  (continued). 

As  connective  tissue  occurs  in  every  organ  of  the  body,  so 
sarcomata  are  anatomically  ubiquitous;  but  they  occur  in  some 
situations  more  commonly  than  others.  They  frequently  grow 
from  the  subcutaneous  tissue  and  fascia,  intermuscular  septa, 
periosteum  and  marrow  of  bone,  the  testis,  ovary,  and  salivary 
glands ;  occasionally  they  grow  in  the  brain,  spinal  cord,  and 
sheaths  of  nerves.  They  are  rare  as  primary  tumours  of  the 
liver  or  lung,  spleen,  alimentary  canal  or  uterus  ;  sarcomata 
grow  from  the  retina  and  uveal  tract,  and  are  fairly  frequent 
in  connection  with  congenital  defects  of  the  skin. 

In  order  to  indicate  the  peculiarities  of  sarcomata  it 
will  be  necessarj'-  to  consider  them  in  relation  with  the  affected 
organs,  and  this  will  allow  their  clinical  features  to  be 
systematically  dealt  with. 

Sarcomata  of  Bone. — When  arising  from  the  periosteum 
these  tumours  are  spoken  of  as  periosteal  or  peripheral  sarco- 
mata ;  those  which  grow  from  the  interior  of  the  bone  are 
termed  central  sarcomata. 

1.  Central  Sarcomata  may  arise  in  the  middle  of  the 
shaft  of  a  long  bone,  but  more  frequently  they  originate 
in  the  cancellous  tissue  near  the  joint-ends  of  the  bone. 
Sarcomata  arising  in  the  diaphysis  belong,  as  a  rule,  to  the 
round-celled  species.  Those  which  grow  at  the  extremities  are 
generally  spindle-celled,  and  contain  a  variable  quantity  of 
myeloid  cells ;  cartilage  is  sometimes  present.  They  occur  at 
any  age,  but  are  most  frequent  between  ten  and  forty,  and 
are  more  common  in  the  long  bones  of  the  lower  than  in  the 
corresponding  bones  of  the  upper  limb. 

When  a  tumour  occupies  the  centre  of  the  dia]3hysis  its 
growth  causes  expansion  of  the  osseous  boundaries,  and  pro- 
duces a  rounded  or  spindle-shaped  swelling,  and  the  bone 
may  become  so  thin  that,  upon  some  slight  exertion,  it  breaks. 
In  cases  where  the  tumour  affects  the  extremity  of  the  bone 
it  will,  in  young  subjects,  infiltrate  the  epiphysis,  but  it  rarely 


SARCOMATA.  79 

transgresses  the  articular  cartilage :  hence  the  contiguous 
joint  is  rarely  invaded  by  a  central  sarcoma. 

Central  sarcomata  rarely  affect  the  adjacent  lymph- 
glands.  In  exceptional  cases,  especially  with  small  round- 
celled  sarcomata,  the  cells  will  make  their  way  along  the 
Haversian  canals  and  form  a  tumour  beneath  the  periosteum. 
Central  sarcomata  lead  to  enlargement  of  the  surrounding 
bone  ;  hence  when  the  soft  tissues  are  removed  by  inaceration 
a  large  bulb-like,  osseous  mass  is  left.  These  specimens  are 
common  in  pathological  museums.  (Fig.  53.)  In  some  cases 
this  osseous  capsule  is  so  thin  that  the  tissue  of  the  tumour 
makes  its  way  through,  and  as  it  is  very  vascular  a  strong 
rhythmical  pulsation  (accompanied  by  a  bruit)  is  perceptible 
over  the  protruding  portion. 

Myeloid  sarcomata  are  always  central  tumours,  and,  like 
the  spindle-  and  round-celled  species,  cause  expansion  of  the 
bone.  These  tumours  have  a  characteristic  maroon  colour  ; 
they  rarely  exceed  a  list  in  size,  grow  with  extreme  slowness, 
and  are  the  least  malignant  of  all  the  species  of  sarcomata. 

2.  Periosteal  Sarcomata. — These  are  often  referred  to  as 
parosteal,  or  peripheral  sarcomata.  They  may  be  round-celled 
or  spindle-celled  (never  myeloid),  and  are  liable  to  the  various 
metamorphoses  and  degenerations  affecting  sarcomata 
generally,  but  are  more  liable  to  calcification  and  ossification 
than  central  tumours.  They  occur  earlier  in  life  than 
those  of  the  preceding  class,  and  are  frequently  associated 
with  antecedent  injury.  They  do  not,  as  a  rule,  invade  joints, 
but  now  and  then  portions  of  them  are  conveyed  into  the 
adjacent  articulation  along  the  ligaments. 

When  growing  from  the  periosteum  near  the  middle  of 
the  shaft,  a  sarcoma  may  be  restricted  to  a  portion  of  its 
circumference  or  entirely  surround  it,  producing  a  fusiform 
swelling.  In  such  specimens  the  shaft  of  the  bone  traverses 
the  tumour  and  may,  beyond  a  slight  amount  of  erosion,  be 
unaffected  by  it.  In  such  a  case,  however,  the  medulla  may 
be  infected  by  the  cells  making  their  way  along  the  Haversian 
canals.  Periosteal  like  central  sarcomata  have  a  greater  pre- 
dilection for  the  joint-ends  of  the  bone  than  for  the  central 
portion  of  its  shaft. 

In  size  periosteal  sarcomata  vary  greatly ;  sometimes  they 


80 


CONNECTIVE    TISSUE    TUMOURS. 


are  of  the  dimeiisions  of  an  orange,  and  thoy  have  been 
recorded  measuring  1  m.  (40")  in  circumference ;  they 
do   not,    as  a  rule,  lead  to  fracture  of  the  bone  from  slight 


Fig.  53.—  Spina  ventosa  of  tlie  fibula.    (Museum,  Middlesex  Hospital.) 


causes,  as  is  the  case  Avith  central  tumours.  Many  of 
them  become  more  or  less  ossified ;  the  ossific  tracts 
may  assume  the  form  of  spicules,  as  in  Fig.  54,  or  the  tumour 
is    traversed   by    an    osseous   mesh,    the  spaces   being   filled 


SARCOMATA.  81 

with  sarcomatous  tissue.  In  some  instances  the  affected  bone 
is  greatly  thickened  in  the  parts  related  to  the  tumour.  The 
extensive  ossification  associated  with  periosteal  sarcomata  is 


Fig.  54. — Skeleton  of  au  ossifying  periosteal  sarcoma  of  the  femur. 

not  a  matter  for  surprise  when  we  remember  that  bone-making 
is  the  essential  function  of  periosteum.  The  crystal-like 
spicules  so  frequently  foimd  in  these  tumours  doubtless 
represent  ossifications  of  the  fibrous  trabecula3  which  normally 
connect  the  periosteum  with  the  compact  tissue  of  the  bone. 
G 


82  CONNECTIVE   TISSUE   TUMOUBS. 

As  tlie  periosteum  is  raised  from  tlie  Lone  by  the  growing 
tumom'  tliese  trabeculse  elongate  and  afterwards  ossify  into 
spicules. 

After  this  general  survey  of  sarcomata  affecting  bone  it 
will  be  useful  to  briefly  consider  the  liability  of  the  various 
bones  to  these  tumours. 

Of  all  bones  the  femur  is  the  one  most  liable  to  sarcomata, 
central  as  well  as  peripheral :  the  tumours  are  most  frequently 
associated  with  its  lower  third,  and  invariably  run  a  rapidly 
fatal  course,  especially  those  which  spring  from  the  periosteum. 
The  duration  of  life  rarely  exceeds  eighteen  months  :  often  it 
is  very  much  less.  They  are  most  frequent  between  the  age 
of  fifteen  and  forty  years. 

Sarcomata  are  fairly  common  in  the  tibia :  they  prefer  the 
upper  to  the  lower  end,  and  do  not  run  such  a  rapid  course  as 
those  of  the  femur,  and  appear  somewhat  later. 

The  fibula  is  not  often  attacked:  the  upper  end  of  the 
bone  is  the  favourite  situation,  but  periosteal  sarcomata  may 
spring  from  any  part  of  its  shaft.     (Fig.  55.) 

Sarcomata  of  the  shaft  of  the  humerus  are  \evy  deadty 
tumours,  and  occur  at  all  ages,  from  infancy  to  extreme  old 
age.  They  generally  involve  the  whole  of  the  cliaphysis, 
and  form  large,  soft,  rapidly-growing,  carrot-shaped  masses. 
Central  tumours  of  the  humerus  usually  attack  the  upjaer 
end. 

The  radius  and  ulna  are  occasionally  the  seat  of  sarcomata; 
the  periosteal  tumours  grow  from  the  middle  of  the  shafts, 
whilst  the  central  varieties  exhibit  a  partiality  for  the  lower 
extremities.  Sarcomata  of  the  clavicle,  sternuvi,  the  hones 
of  the  hands  and  feet,  and  the  ribs  are  excessively  rare. 
Sarcomata  of  the  ribs  usually  spring  from  the  neck  or  head 
of  the  bone,  and  are  liable  to  send  processes  through  the 
intervertebral  foramina  and  compress  the  cord. 

The  scapula  and  hip  bone  are  sometimes  attacked  by  sar- 
comata. In  the  case  of  the  scapula  the  tumour  usually  springs 
from  the  bod}^  of  the  bone ;  exceptionally,  the  seat  of  origin  has 
been  the  coracoid  process.  Of  the  various  parts  of  the  hip 
bone  the  ilium  is  most  often  attacked.  The  skull  bones 
are  by  no  means  uncommon  situations  for  sarcomata,  but 
they  are  attacked  much  later  in  life  than  the  long  bones. 


SARCOMATA. 


83 


Of  the   various    bones    of   the   skull,    two    call   for   especial 
mention — viz.,  the  maxilla  and  mandible. 

Sarcomata  of  the  Jaws. — Although  it  is  customary  to 
speak  of  tumours  connected   with  the  maxilla  or  mandible 


Accessory      iwdulc      of 
sarcoma. 


Interosseous  laembrane. 


Flexor  longus  liallucis. 


Peroneus  longus. 

Detached  portion  of  the 
flexor  longus  hallucls. 


Fig.  5.5.— Spindle-celled  sarcoma  of  the  fibula.     (Muaenni,  Middlesex  Hospital.) 


clinically  as  tumours  of  the  jaws,  it  would  be  erroneous  to 
describe  them  indiscriminately  as  tumours  of  bone. 

In  each  jaw  there  are,  in  addition  to  the  bone  and  its 
periosteum,  two  structures  to  consider— mucous  membrane 
and  teeth.     In  the  case  of  the  maxilla,  the  antrum  must  be 


84  CONNECTIVE    TISSUE    TUMOULS. 

considered  ;  in  addition,  the  maxilla  is  liable  to  Ije  invaded  by 
sarcomata  arising  in  the  naso-pharynx,  orbit,  and  nasal  fossa. 

Sarcomata  of  the  jaws  may  arise  from  the  pcriostenm  or  the 
muco-periosteum ;  in  either  case  they  are  of  the  round-celled 
or  spindle-celled  species.  When  springing  from  the  gums  sar- 
comata are  often  spoken  of  as  malignant  epulides.  The  term 
epulis  has  only  a  topographical  significance.  Sarcomata  arising 
in  the  follicles  of  teeth  are  often  confounded  with  central 
tumours. 

Periosteal  sarcomata  originate  in  any  part  of  the  maxilla, 
but  they  rarely  arise  from  its  facial  surface,  and,  though  fairly 
frequent  on  the  gums,  are  very  rare  in  connection  with  the 
mucous  membrane  of  the  palatine  process.  The  muco- 
periosteum  of  the  antrum  is  a  common  situation  for  these 
tumours,  and  as  they  grow  lead  to  thinning  and  expansion  of 
the  walls  of  this  chamber.  This  enlargement  of  the  body  of 
the  maxilla  causes  it  to  encroach  on  the  nasal  fossa  and 
obstruct  respiration  ;  often  the  tumour  pushes  up  the  orbital 
plate  and  displaces  the  eyeball  (proptosis)  and  in  a  certain  pro- 
portion of  cases  the  alveolar  border  is  depressed.  The  nasal 
duct  is  frequently  implicated,  and  when  completely  obstructed 
epiphora  is  the  consequence.  Clinically,  a  sarcoma  originating 
within  the  antrum  behaves  like  a  central  tumour  in  a 
long  bone,  and  by  degrees  processes  of  the  tumour  make  their 
way  through  the  thin  walls  and  implicate  the  skin  of  the  cheek, 
or,  projecting  into  the  nasal  fossa,  ulcerate,  and  give  rise  to 
frequently  recurring  haemorrhage.  When  the  tumour  makes  its 
way  through  the  posterior  wall  of  the  antrum  it  will  enter 
the  zygomatic  and  spheno-maxillary  fossi^e,  and  creep  thence 
into  the  temporal  fossa,  or  make  its  way  through  the  spheno- 
maxillary fissure  and  ramify  in  the  orbit,  or  steal  through  the 
sphenoidal  fissure  or  foramen  rotundum  into  the  middle  fossa 
of  the  cranium. 

Sarcomata  growmg  from  the  gums  project  usually  into  the 
space  between  the  teeth  and  the  cheeks  ;  such  tumours,  when 
large,  stretch  the  cheeks  and  often  produce  great  displacement 
of  the  teeth  on  the  afiected  side,  and  marked  alterations  in  the 
conformation  of  the  alveolar  borders  of  the  jaws.  When  the 
tumour  is  unusually  large  it  will  protrude  beyond  the  lips. 
Periosteal  sarcomata  of  the  jaws  are  very  rare  before  the 


SARCOMATA.  85 

age  of  fifteen  years,  but  they  occasionally  happen  in  very  young 
children.  The  usual  period  of  life  at  which  they  grow  is 
between  the  twentieth  and  sixtieth  years. 

Periosteal  sarcomata  are  less  frequent  on  the  mandible 
than  the  maxilla ;  they  may  grow  from  any  part  of  it,  and 
sometimes  attain  a  large  size.  The  spindle-celled  species  is 
very  apt  to  contain  cartilage,  and  this  tissue  may  be  very 
abundant.  Sarcomata  springing  from  the  outer  surface  of  the 
ramus  are  apt  to  be  mistaken  for  parotid  tumours. 

Myeloid  Sarcomata  are  very  rare  in  the  maxilla,  and,  as  a 
rule,  arise  in  connection  with  the  nasal  process ;  although  they 
grow  slowly,  such  tumours  sometimes  attain  a  large  size.  In 
the  mandible  they  spring  usually  from  the  body  of  the 
bone. 

To  judge  from  the  descriptions  current  in  text-books,  it 
would  be  imagined  that  myeloid  sarcomata  are  fairly  frequent 
in  the  alveolar  borders  of  the  jaws ;  this  error  is  due  to  the 
circumstance  that  sufficient  attention  has  not  been  devoted 
to  sarcomata  arising  in  connection  with  developing  teeth. 
When  specimens  preserved  in  museums  as  examples  of 
myeloid  sarcomata  of  jaws  are  critically  examined  they  will 
be  found  to  fall  into  three  categories : — 1,  Fibrous  odontomes  ; 
2,  sarcom.ata  originating  in  the  follicles  of  teeth ;  3,  myeloid 
sarcomata. 

Fibrous  odontomes  have  already  been  considered,  and  the 
presence  of  the  few  multinucleated  cells  they  contain  ex- 
plained.    (Page  34.) 

Sarcomata  arising  in  the  follicles  of  teeth  are  composed  of 
small  round,  and  spindle  cells,  with  a  few  multinuclear  cells 
interspersed.  In  their  early  stages  these  tumours  are  distinctly 
encapsuled,  but  as  they  increase  in  size  and  involve  the  gums, 
the  exposed  surfaces  ulcerate,  and  give  rise  to  hemorrhage. 
When  ulceration  occurs,  the  neighbouring  lymph  glands  are 
apt  to  become  infected. 

Sarcoma  of  a  tooth  follicle  only  occurs  in  children,  and  is 
particularly  apt  to  involve  the  germ  of  the  first  perriianent 
molar.     (Fig.  56.) 

When  suspected  cases  are  critically  examined,  myeloid  sar- 
comata of  the  jaws,  as  in  other  parts  of  the  skeleton,  will  be 
found  somewhat  unusual  tumours.     They  are  rarely  met  with 


86  CONNECTIVE   TISSUE   TUMOURS. 

after  the  twenty-fifth  year,  and  in  the  jaws,  as  elsewhere,  are 
the  least  malignant  species  of  sarcomata. 

It  has  been  mentioned  that  the  maxilla  is  very  apt  to 
become  involved  by  sarcomata  springing  from  adjacent  parts, 
and  this  is  a  very  important  clinical  fact  to  bear  in  mind. 
This  invasion  may  take  place  from  two  sources  ;  in  particular, 
the  naso-pharynx  and  nasal  fossa. 

Spindle-celled  sarcomata  occasionally  arise  in  that  portion 
of  the  pharyngeal  mucous  membrane  which  covers  the  under 
surface  of  the  body  of  the  sphenoid  and  forms  the  roof  of 
the  naso-pharynx.     It  is  not  uncommon  for  such  tumours  to 

Mandibular  llel^e 
Developing  tooth. 
Sarcoma. 


Fig.  56. — Sarcoma  arising  in  the  follicle  of  a  developing  tooth.     (The  dotted  lines  indicate 
the  amount  of  the  mandible  removed  at  the  operation.) 


extend  into  and  plug  one  or  both  nasal  fossaa,  processes  of  the 
tumour  appearing  at  the  nostril ;  or  they  may  extend  down- 
wards into  the  pharynx  and  impede  deglutition.  Sometimes 
the  base  of  the  skull  is  perforated  by  the  tumour,  and  the 
patient  dies  of  meningitis.  Naso-pharyngeal  sarcomata  give 
rise  to  agonising  pain  and  intense  frontal  headache.  Whilst 
the  pain  wears  out  the  patient,  strength  is  further  exhausted 
by  frequently  recurring  and  often  profuse  epistaxis.  Excep- 
tionally, a  piece  of  the  tumour  will  slough  and  become  im- 
pacted in  the  larynx;  suftbcation  has  followed  this  accident. 
Naso-pharyngeal  sarcomata  are  chiefly  met  with  in  patients 
between  the  age  of  fifteen  and  twenty. 

Sarcomata  arising  in  the  nasal  fossa  and  invading  the 
antrum  are  not  very  common.  One  of  the  most  remarkable 
cases  illustrating  this  has  been  recorded  by  Moore.*     In  this 

*  Trans.  Path.  Soc,  vol.  xix.  332. 


SARCOMATA. 


87 


instance  a  mixed-celled  sarcoma  arose  in  connection  with  the 
nasal  septum  and  spread  laterally  into  each  antrum.  As  it  in- 
creased in  size  the  space  between  the  orbits  widened,  and  at  the 
same  time  the  face  projected  forwards,  producing  the  dreadful 
deformity  depicted  in  Fig.  57.  One  of  the  most  extraordinary 
features  in  this  unusual  case  was  the  entire  absence  of  pain  or 
cerebral  disturbance  ;  the  sense  of  smell  was  lost  and  the  sight 
of  the  right  eye  impaired.     Moore  attempted  the  formidable 


Fig.  57.— Deformity  produced  by  a  sarcoma  of  the  nasal  septum.    (Moore's  case.) 

task  of  removing  this  tumour,  but  the  patient  died  during  its 
progress,  in  consequence  of  some  interference  with  respiration. 

An  examination  of  the  parts  showed  that  the  tumour  was 
surrounded  by  a  thick  osseous  capsule,  its  wall  being  continuous 
with  that  portion  of  the  nasal  septum  formed  by  the  mes- 
ethmoid  (Fig.  58) ;  as  the  tmnour  increased  in  size  it  invaded 
each  antrum,  but  its  bony  capsule  remained  separate  from 
the  maxillfe. 

Sarcomata  of  the  Retina. — These  tumours  are  often 
called  gliomata ;  formerly  they  were  known  as  medullary 
cancer,  encephaloid  tumours,  or  fungus  htematodes. 

A  retinal  sarcoma,  in  structure,  mimics  the  cells  composing 
the  granular  layer  of  the  retina.  It  occurs  exclusively  in 
children.     Exceptionally  the  tumour  may  be  noticed  at  birth; 


88  CONNECTIVE   TISSUE  TUMOURS. 

more  cominonly  it  makes  its  appearance  during  the  first  four 
years  of  life  ;  it  is  very  rare  after  the  seventh  year,  and  is 
almost  unknown  after  the  age  of  twelve.  In  a  certain  propor- 
tion of  cases  (twenty  per  cent.)*  both  retinte  are  affected,  either 
simultaneously  or  after  a  brief  interval.  This  is  always  an 
indication  that  the  tumour  is  highly  malignant.  In  the  early 
stages  there  is,  as  a  rule,  no  pain  or  symptom  denoting  the 
presence  of  a  tumour  ;  gradually  the  pupil  dilates,  and  a  pecu- 


Fig.  58. — Facial  region  of  tlie  sl'cnll  from  tlie  case  shown  in  tlie  preceding  figure,  seen  in  sagittal 
section.     The  sarcoma  is  restricted  to  tlie  nasal  septum.     (Museum,  Middlesex  Hospital.) 

liar  reflex  is  noticed  at  the  fundus  (this  is  often  termed  cat's- 
eye),  and,  on  testing,  the  eye  will  be  found  quite  blind.  As  soon 
as  the  existence  of  a  glioma  is  discovered  by  the  surgeon,  the 
eye  is,  as  a  rule,  promptly  excised.  In  cases  where  treatment 
of  this  kind  is  refused  or  deferred,  the  following  changes  occur. 
The  tumour,  continuing  to  increase,  pushes  forward  the  intra- 
ocular structures  and  induces  great  pain  as  the  result  of  the 
increased  intra-ocular  pressure  it  produces,  until  the  cornea 
yields  and  the  tumour  bursts  forth,  and,  growing  very  rapidly, 
soon  makes  its  way  between  the  eyelids,  which  become  swollen 

*  Lawford  and  Collins,  Eoy.  Lond.  Ophth.  Hosp.  Eep.,  vol.  xiii.,  p.  1. 


SARCOMATA.  89 

and  everted,  and  then,  in  consequence  of  exposure,  assumes  a 
dusky  red  flesliy  appearance,  whilst  from  its  surface  a  sanious 
fluid  exudes  which  may  form  crusts  on  the  surface  of  the 
tumour.  Should  the  parts  become  excoriated  or  handled,  they 
bleed  freely.  A  fungating  tumour  of  this  kind  will  sometimes 
attain  a  very  large  size  before  it  destroys  the  child's  life. 

After  excision  of  an  eye  for  retinal  sarcoma  the  disease  is 
very  prone  to  recur,  and  the  recurrent  tumour  may  attain  very 
large  proportions  before  it  destroys  life.  There  is  a  specimen 
in  the  museum  of  the  Middlesex  Hospital  which  well  illus- 
trates the  malignant  characters  of  some  retinal  sarcomata.  The 
patient,  a  girl  two  years  of  age,  had  a  tumour  in  each  eye.  In 
December,  1883,  Mr.  G.  Lawson*  excised  the  right  eye;  in 
January,  1884,  the  left  was  removed  on  account  of  the  pain 
caused  by  the  tumour.  A  month  later  the  sarcoma  recurred 
in  the  left  orbit,  and  grew  so  rapidly  that  in  August  there  was 
a  large  tumour  extending  over  the  left  half  of  the  child's  face 
like  a  huge  cauliflower.  She  died  eight  months  after  the  re- 
moval of  the  right  eye.  Secondary  deposits  were  found  in  the 
right  deltoid,  on  the  dura  mater,  and  a  mass  as  large  as  an 
orange  was  connected  with  the  optic  commissure  and  occupied 
the  sella  turcica. 

The  disease  in  this  case  was  exceptional  in  the  rapidity  of 
its  growth,  the  large  size  to  which  the  recurrent  tumour 
attained,  and  the  presence  of  secondary  deposits,  which  are 
the  exception  rather  than  the  rule.  When  an  eye  is 
excised  for  retinal  sarcoma,  and  especially  when  the  operation 
has  been  long  delayed,  the  growth  may  have  burst  through  the 
sclerotic  and  invaded  the  orbital  tissues  ;  in  a  larger  proportion 
of  cases  it  has  infiltrated  the  optic  nerve,  and  it  is  in  this 
structure  that  the  disease  reappears.  The  frequency  with 
which  sarcoma  returns  in  the  stump  of  the  optic  nerve  is,  in 
all  probability,  due  to  the  intimate  lymphatic  relations  of  this 
nerve  with  the  intra-ocular  lymph  sj^aces. 

*  Trans.  Path.  Poc,  vo\  xxxvi.,  418. 


90 

CHAPTER    X. 

SARCOMATA  (contiiiued). 

Sarcomata  of  Secreting-  Glands. — In  describing  spindle-celled 
sarcomata  it  was  mentioned  that  it  is  no  uncommon  condi- 
tion to  find  tracts  of  hyaline  cartilage,  usually  of  an  immature 
type,  in  the  substance  of  the  tumour.  When  the  cartilage 
is  fairly  abundant,  the  tumour  is  usually  described  as  a  chon- 
clrifying  sarcoma.  In  addition  to  bone,  tumours  of  this 
character  occur  in  the  parotid,  submaxillary,  and  lachrymal 
glands ;  in  the  testis  and  in  the  mamma.  In  the  case  of  the 
salivary  glands  and  the  testis  the  cartilage  often  constitutes 
the  main  mass  of  the  tumour,  which  is,  under  such  conditions, 
erroneously  described  as  a  chondroma. 

1.  Parotid  Sarcomata. — These  appear  as  oval,  smooth, 
and  elastic  swellings  in  the  parotid  immediately  in  front  of  or 
behind  the  angle  of  the  mandible  ;  increasing  in  size,  they 
become  tuberous  and  may  implicate  the  tragus.  Left  to  them- 
selves, they  burrow  deeply  among  the  tissues  of  the  neck,  dip 
beneath  the  sterno-mastoid,  and  acquire  attachments  to  the 
carotid  sheath ;  sometimes  they  creep  upwards  and  adhere  to 
the  under  surface  of  the  petrosal,  and  pushing  towards  the 
middle  line,  so  bulge  the  pharyngeal  w^all  inwards  as  to  impede 
deglutition.  Rapidly  growing  tumours  tend  to  involve  the 
skin  and  ulcerate;  in  very  large  tumours  semi-fluctuating 
spaces  form  in  consequence  of  degenerate  (mucoid)  changes. 

The  facial  nerve  is  usually  involved  in  large  parotid 
tumours;  the  small  specimens  which  burrow  behind  the 
ramus  of  the  mandible  often  implicate  the  nerve  as  it  issues 
from  the  stylo-mastoicl  foramen. 

Structurally,  these  tumours  exhibit  extraordinary  variety. 
Some  consist  entirely  of  hyaline  cartilage  arranged  in  lobules 
bound  together  by  loose  connective  tissue.  The  cells  of  the 
cartilage  rarely  possess  capsules,  and  are  often  stellate,  as  in 
immature  cartilage.  Such  grow  Avith  extreme  slowness,  and 
rarely  exceed  a  bantam's  egg  in  size,  and  may  require  ten  or 
even  twelve  years  to  attain  such  proportions. 

The  large,  rapidly  growing  tumours  consist  of  spindle  cells 


SARCOMATA. 


91 


in  wliich  tracts  and  islets  of  hyaline  cartilage  are  interspersed. 
Wlien  cliondral  tissue  is  abundant,  it  is  very  prone  to  mucoid 
changes,  and  soft,  fluctuating  spaces  are  formed.  The  con- 
nective tissue  is  very  liable  to  undergo  myxomatous  change, 
and,  as  if  to  render  these  tumours  more  complex,  portions  of 
the  secreting  tissue  of  the  gland  are  imprisoned  in  them. 

It'  is  not  unusual  in  sections  from  a  parotid  sarcoma  to 
meet  with  spindle  cells,  cartilage,  myxomatous  tissue,  glandular 


Fig.  59. — Parotid  sarcoma  ijiiplicatiiig  the  pinna  in  a  woman  thirty-five  years  of  age. 

acini,  and  fibrous  tissue  in  an  area  2  cm.  square.  Exceptionally 
striped  spindle  cells  are  seen.  Parotid  tumours  of  such  com- 
plex structure  grow  rapidly  and  attain  a  large  size,  and  often 
infiltrate  the  surrounding  tissue  and  skin.  Some  of  them 
infect  the  adjacent  Ijanph  glands  and  give  rise  to  secondary 
deposits  in  the  lungs. 

Chondrifying  sarcomata  of  the  parotid  are  most  frequently 
met  with  between  the  fifteenth  and  thirty-fifth  years,  but  they 
have  been  observed  as  late  as  the  seventy-fourth  year.  They 
present  very  characteristic  features.  (Fig.  59.)  In  their  early 
stages    they   are   easily   removed,    but   many  of  the  rapidly 


i)-2  CONNECTIVE   TISSUE   TUMOUES. 

growing   forms   so    quickly   infiltrate    the    tissues  that  their 
complete  extirpation  is  not  always  possible. 

AVhen  left  to  themselves  they  cause  death  in  a  variety 
of  ways.  .  Thus  they  may  press  upon  the  phar3mx  and 
lead  to  fatal  dysphagia,  or  ulceration  may  open  some  large 
vessel  in  the  neck  and  produce  fatal  hsemorrhage ;  secondary 
nodules  sometimes  form  in  the  lungs  and  induce  fatal 
broncho-pneumonia. 

2.  Chondrifying"  Sarcomata  of  the  Submaxillary  Gland. 
— These  tumours  are  far  less  frequent  in  the  submaxillary 
than  in  the  parotid  gland.  They  are  distinctly  encapsuled 
and,  as  a  rule,  shell  out  easily.  They  grow  slowly  and  occur  in 
the  young  as  well  as  in  adults,  but  they  do  not  appear  to 
attain  so  large  a  size  as  in  the  case  of  the  parotid.  Butlin* 
has  described  a  typical  case,  and  gives  references  to  a  few 
other  examples.  As  in  the  case  of  parotid  sarcomata,  gland- 
ular tissue  is  often  associated  with  the  cartilage. 

3.  Chondrifying  Sarcomata  of  the  Lachrymal  Gland. — 
Tumours  containing  cartilage  are  very  rare  in  this  gland. 
Butlinf  has  described  an  example  removed  by  Yernon  from 
the  orbit  of  a  man  twenty-eight  years  of  age.  The  tumour  had 
been  growing  nine  years  ;  it  was  easily  shelled  out  of  a  tough 
capsule,  and  measured  6  by  4  cm.  Seven  years  later  the 
man  was  free  from  recurrence. 

4.  Sarcomata  of  the  Pancreas.  —  Connective -tissue 
tumours  of  the  pancreas  are  very  rare.  I  have  not  succeeded 
in  finding  a  specimen  or  description  of  a  chondrifying  sarcoma 
of  the  pancreas. 

Sarcomata  of  the  Testicle. — This  gland  is  somewhat  prone 
to  sarcomata ;  the  two  varieties,  round-celled  and  spindle- 
celled,  occur  in  about  equal  proportion.  Lympho-sarcomata 
occur  occasionally.  Butlin|  has  pointed  out  that  the  disease 
is  most  frequent  at  two  periods  of  life  :  the  first  period  begins 
at  birth  and  ends  with  the  tenth  year ;  the  second  period  is 
from  the  thirtieth  to  the  fortieth  years. 

It  is  not  rare  to  find  both  testes  affected  in  cases  of  round- 

*  Trans.  Path.  Soc,  vol.  xxviii.  228.  {See  also  Lane,  Trans.  Clin.  Soc, 
vol.  xxiv.,  17). 

f  Trans.  Path.  Soc,  vol.  xxvi.,  184. 
1  "  Sarcoma  and  Carcinoma,"  London. 


SARCOMATA.  93 

■celled  sarcomata,  and  in  this  respect  there  is  an  interesting 
analogy  between  this  species  of  sarcoma  in  the  testis,  ovary, 
and  retina. 

Spindle-celled  sarcoma  of  the  testis  only  attacks  one 
testicle;  in  about  one-half  the  cases  the  tumours  contain 
hyaline  cartilage,  and  in  some  the  amount  of  cartilage  is  so 
large  that  they  have  been  described  as  "  enchondromata "  of 
the  testis. 

Occasionally  the  cartilage  assumes  the  form  of  tubes  or 
cylinders  disposed  like  the  tubules  of  the  testis.  One  of  the 
best  examples  is  the  classical  case  described  by  Sir  James 
Paget.*  The  secondary  deposits  associated  with  chondrifying 
testicular  sarcomata  contain  cartilage,  and  in  a  fcAv  instances 
this  tissue  is  more  abundant  in  the  secondary  nodules  than 
in  the  primary  tumour.  Spindle  cells  with  transverse  striation 
occasionally  occur. 

Spindle-celled  sarcomata  of  the  testis  in  their  structure 
and  life  history  are  parallel  with  jjarotid  sarcomata,  and,  like 
these  tumours,  are  occasionally  composed  almost  entirely  of 
cartilaofe.  Butlin  has  described  a  case  in  Avhich  castration 
was  performed  in  1875  on  a  man,  twenty-one  years  of  age, 
for  a  small  tumour  of  the  testis  which  had  been  growing  four 
years.  It  was  composed  of  hyaline  cartilage  with  a  capsule 
of  iibrous  tissue,  and  septa  of  the  same  tissue  traversed  the 
cartilage.     The  man  was  in  good  health  in  1879. 

Lympho-sarcomata  of  the  testis  are  often  included  in  the 
round-celled  species ;  this  is  unfortunate,  as  the  lympho- 
sarcomata  are  even  more  malignant  than  the  round-celled 
tumours,  and  disseminate  much  more  rapidly.  It  is  also 
well  established  that  they  not  infrequently  attack  both 
testes  either  simultaneously  or  after  a  brief  interval. 

The  clinical  recognition  of  sarcoma  of  the  testis  is  not  by 
any  means  a  simple  matter ;  it  is  often  impossible  to  dis- 
tinguish between  a  hsematocele  and  a  solid  tumour.  The 
points  on  which  it  is  best  to  rely  are  the  weight  of  the  tumour 
and  absence  of  inflammation,  syphilis,  and  translucency. 
Some  sarcomata  are  intensely  hard,  others  are  soft  and  almost 
fluctuate ;  most  of  them  are  painless,  but  a  few  are  the  seat  of 
continual  pain. 

*  Med.  C'liir.  Trans.,  vol.  xxxviii.  247. 


94  CONNECTIVE    TISSUE    TUMOURS. 

Ovarian  Sarcomata. — The  ovary  is  occasionally  the  seat 
of  sarcoma  ;  the  round-  and  spindle-celled  species  occur  in 
about  equal  proportion.  Both  ovaries  are  simultaneously 
affected  in  about  twenty  per  cent,  of  the  cases ;  in  this  respect 
sarcomata  of  the  ovaries  resemble  those  of  the  testis  and 
retina.  The  similarity  of  ovarian  and  retinal  sarcomata  is 
further  illustrated  by  the  fact  that  they  are  most  frequent  in 
young  children.  For  instance,  in  seventy  recorded  cases  of 
ovarian  cysts  and  tumours  removed  from  girls  under  fifteen 
years  of  age,  twelve  were  examples  of  sarcomata.  In  com- 
jDrehensive  ovariotomy  lists  solid  tumours  make  up  five  per 
cent,  of  the  cases,  and  this  includes  fibromata  and  myomata, 
as  well  as  sarcomata,  occurring  at  all  periods  of  life.  A  careful 
study  of  cases  shows  that  sarcomata  of  the  ovaries  are  four 
times  more  frequent  in  girls  under  fifteen  years  of  age  than  in 
adult  women. 

At  whatever  period  of  life  they  appear,  ovarian  sarcomata 
grow  rapidly,  and  are  invariably  associated  with  free  fluid  in 
the  peritoneum ;  in  the  later  stages  of  the  disease  fluid 
accumulations  may  occur  in  one  or  both  pleural  cavities. 

Ovarian  sarcoma  in  the  young  and  in  adults  runs  a 
rapidly  fatal  course. 

Sarcomata  of  the  Mammary  Gland. — The  mamma  is 
occasionally  the  seat  of  a  sarcoma,  and  when  we  take  into  con- 
sideration the  large  amount  of  connective  tissue  which  it  often 
contains,  it  is  somewhat  surprising  that  these  tumours  are  not 
more  frequent.  As  is  the  case  with  sarcomata  growing  in  the 
parotid  gland,  these  tumours,  originating  in  the  connective 
tissue  of  the  breast,  usually  entangle  the  ducts  and  acini  in 
their  immediate  neighbourhood ;  such  mcorporated  glandular 
structures  occasionally  give  rise  to  cystic  spaces,  which,  when 
viewed  in  section  under  the  microscope,  exhibit  a  regular 
lining  of  epithelium.  Such  tumours  are  often  called  "  adeno- 
sarcomata."  This  is  a  misuse  of  the  term  sarcoma,  and  it  has 
unfortunately  been  extended  so  as  to  include  many  adenomata 
of  the  breast,  especially  if  they  should  happen  to  grow  rapidly 
or  attain  a  large  size. 

The  breast  is  liable  to  round-  and  spindle-celled  sarcomata. 
The  round-celled  species  rapidly  infiltrate  the  organ  and 
invade  adjacent  structures,  giving  rise  to  brawn}^  indurated 


SARCOMATA.  95 

tumours.     They  recur  very  quickly  after  removal,  and  grow 
with  fearful  rapidity  in  women  who  are  suckling. 

Spindle-celled  sarcomata  grow  slowly,  and  in  the  few 
reported  cases  the  tumour  had  attained  the  proportion  of  an 
orange  before  removal.  In  the  breast,  as  in  the  case  of  the 
salivary  glands  and  testis,  such  tumours  occasionally  contain 
tracts  of  hyaline  cartilage-  and  even  well-formed  bone.f 

*  Bowlby,  Trans.  Path.  Soc,  vol.  xxxiii.  306. 
f  Battle,  Ti-ans.  Path.  Soc,  vol.  xxxvii.  473. 


96 


CHAPTER    XI. 

SARCOMATA  (continued). 

Myo-sarcomata  (rhabdomyomata).^ — It  is  a  remarkable  fact, 
considering  the  large  amount  of  striped  muscle  tissue  existing 
in  the  body,  that  tumours  composed  of,  or  containing,  this 
tissue  do  not  arise  in  connection  with  the  voluntary  muscles, 
but  make  their  appearance  in  such  unexpected  situations  as 
the  kidney,  testis,  neck  of  the  uterus,  parotid  gland,  and  in 
parosteal  lipomata,  organs  and  tissues  which,  under  normal 
conditions,  do  not  contain  muscle  cells  of  the  striped  variety. 

Before  discussing  the  probable  origin  of  striped  muscle 
cells  in  anomalous  situations,  it  will  be  necessary  to  consider 
the  characters  of  the  tumours  in  which  they  occur,  for  more 
extended  observations  have  brought  to  light  many  facts  which 
serve  materially  to  modify  the  earlier  speculations  on  this 
question. 

1.  Renal  Sarcomata. — The  following  species  of  sarcomata 
occur  in  the  kidney:— (1)  Spindle-celled  sarcoma  and  its 
variety,  myo-sarcoma  ;  (2)  Round-celled  sarcoma  ;  (3)  Tumours 
composed  of  adrenal  tissue. 

The  most  remarkable  feature  concerninsf  renal  sarcomata 
is  that  in  a  very  large  proportion  of  cases  they  are  congenital, 
or  are  noticed  within  a  few  months  of  birth. 

Congenital  Renal  Sarcomata  exhibit  the  following 
characters.  These  tumours  grow  very  rapidly  and  attain 
large  dimensions  in  the  course  of  a  few  months ;  they  are,  as 
a  rule,  painless.  Death,  which  usually  occurs  before  the  end 
of  the  third  year,  is,  in  most  cases,  due  to  mechanical  causes  ; 
the  large  size  of  the  tumour  causes  it  to  push  up  the  diaphragm, 
encroach  upon  the  thoracic  cavity,  and  impede  respiration. 

In  about  half  the  cases  both  kidneys  are  affected ;  when 
only  a  portion  of  the  gland  is  involved  the  tumour  is  isolated 
from  the  renal  tissue  by  a  capsule.  On  section  the  sarcoma 
presents  a  yellowish- white  colour,  dotted  here  and  there  with 
groups  of  small  cavities  due  to  secondary  changes.  The  basis 
of  the  tumour  is  connective  tissue  containing  cells  of  various 


SARCOMATA.  97 

shapes  and  sizes ;  some  are  round  or  oat-shaped,  and  others 
are  spindles.  In  many  specimens  a  large  proportion  of  the 
tumour  is  composed  of  fasciculi,  which  present  the  cross 
striation  so  characteristic  of  the  fibres  of  voluntary  muscle ; 
when  these  cells  are  isolated  they  appear  as  elongated  spindles 
furnished  with  a  large  nucleus  and  transversely  striated ;  in 
some  of  them  there  is  also  an  oblique  striation.  The  cells 
are  without  a  sarcolemma. 

The  second  variety  of  renal  sarcoma  has  been  called 
"  congenital  adeno-sarcoma  "  (a  very  misleading  name)  because 
it  contains  groups  of  tubules  lined  with  regular  cubical 
epithelium,  so  that  on  section  they  convey  an  appearance 
like  that  afforded  by  a  number  of  renal  tubules  in  transverse 
section.  An  examination  of  several  examples  of  these 
tumours  and  a  careful  study  of  the  descriptions  published  by 
others,  make  it  appear  that  when  the  striped  cells  are  very 
abundant  the  epithelial-lined  tubules  are,  as  a  rule,  absent, 
and  when  the  tubules  are  numerous  it  may  be  necessary  to 
examine  many  sections  before  the  striated  cells  are  detected. 
In  the  two  conditions  the  round,  oat-shaped,  and  spindle  cells 
are  equally  abundant. 

It  has  been  suggested  by  Paul  that,  as  the  most  typical 
myo-sarcomata  are  more  sharply  delimited  from  the  kidney 
than  the  other  varieties,  the  tubular  elements  may  be  derived 
from  the  kidney ;  my  own  inquiries  do  not  support  this  view. 
Renal  myo-sarcomata  are  well  supplied  with  blood-vessels, 
and  do  not,  as  a  rule,  give  rise  to  secondary  deposits. 

Ribbert,  in  an  interesting  paper,  has  collected  the  scattered 
literature  relating  to  these  tumours,  and  enriched  it  by  some 
new  observations.  He  refers  to  two  cases  described  in 
"  Dissertations  at  Bonn,  1891,"  in  which  tumours  containing- 
striated  spindles  occupied  the  pelvis  of  the  kidney.  One 
case  was  obtained  from  an  adult  man,  the  other  from  a  child 
eight  years  and  a  half  old. 

Renal  sarcomata  of  the  round-  and  spindle-celled  species 
occur  in  adults ;  they  are  less  common  than  in  infants,  and 
differ  from  them  in  two  important  points : — 

(1)  It  is  rare  for  both  kidneys  to  be  affected. 

(2)  Striated  cells  are  very  rarely  present. 

They  may  occur  at  any  age,  but  an  examination  of  a  large 

H 


98  CONNECTIVE    TIHHIJE   TUMOTJRH. 

number  of  records  indicates  that  the  period  Ijetwecn  the  tifth 
and  thirtieth  years  of  life  is  singularly  free  from  renal  sarco- 
mata. They  seem  to  occur  equally  in  men  and  women.  The 
effects  which  they  produce  are  similar  to  those  of  sarcomata 
in  other  organs.  Occasionally  a  process  of  the  tumour  will 
make  its  way  into  the  pelvis  of  the  kidney  and  travel  down 
the  ureter  in  the  same  manner  that  sarcomatous  out-runners 
make  their  way  along  the  lumina  of  veins  whenever  they 
manage  to  penetrate  the  walls  of  these  vessels.  (See  page  74.) 
When  the  ureter  is  thus  invaded  small  fragments  of  the 
tumour  are  detached  and  conveyed  by  the  urine  into  the 
bladder,  to  be  expelled  during  micturition.  This  fact  is  worth 
remembering,  as  it  is  sometimes  of  assistance  in  diagnosis. 

It  is  necessary  to  mention  that  a  ureter  may  be  involved 
in  a  sarcoma  arising  in  its  neighbourhood  ;  the  walls  become 
infiltrated,  and  then  a  process  of  the  tumour  may  project  into 
its  lumen.  Exceptionally,  a  process  from  a  sarcoma  of  the 
bladder  w^ill  enter  the  vesical  orifice  of  the  ureter  and  travel 
along  it  for  a  considerable  distance. 

Much  uncertainty  must  exist  in  drawing  conclusions  from 
old  records  of  renal  sarcomata,  because  it  is  now  clear  that 
many  tumours  of  the  kidney  in  adults,  which  have  been 
described  as  sarcomata,  were,  in  many  instances,  composed  of 
tissue  similar,  if  not  identical,  in  structure  with  that  which 
forms  the  zona  fasciculata  of  the  adrenal  (suprarenal  capsule). 
(Fig.  60.)  It  is  quite  certain  that  some  specimens  regarded 
as  sarcomata  of  the  kidney  turn  out  on  critical  investigation 
to  be  tumours  of  the  adrenals  ;  it  will  therefore  be  necessary 
to  consider  tumours  of  the  adrenal  as  a  sequel  to  renal 
sarcomata. 

Adrenal  Tumours. — There  are  two  varieties  of  tumour 
which  come  under  this  heading  : — (1)  Tumours  of  the  adrenal. 
(2)  Tumours  of  accessory  adrenals. 

There  is  sufficient  evidence  forthcoming  to  demonstrate 
that  an  adrenal  may  become  transformed  into  a  large  tumour 
in  the  same  way  that  the  thyroid  gland  becomes  a  goitre ; 
indeed,  the  analogy  is  so  striking  that  Virchow,  years  ago, 
proposed  for  such  enlarged  adrenals  the  term  "  struma  supra- 
renalis."  The  museum  of  the  Royal  College  of  Surgeons 
contains  two  good  specimens  of  enlarged  adrenals,  one  of  which 


SAEGOMATA. 


99 


weighed  eleven  pounds.*     They  were  removed  from  patients 
aged  fifty-three  and  thirty-six  years  respectively. 

Similar    tumours  (adrenal  goitres)    also    occur   in   other 
mammals.     In  1885  I  detected  in  a  marmot  {Gynomys  lado- 


Blood-vessels. 


Blood-vessels. 


^"""i; 

x-     ^ 


The  tuiiioui.  / ,  5-      '  1  (. 


Fibrous  tissue 
of  the  capsule. 


Hyaline  de- 
generation of  a 
vessel. 


Capsule 
Fig.  60. — Micioscopic  il  thaidLtti'5  ot  a  tuiaoui  aiismg  in  an  accessory  adrenal.    (Graiuitz.) 


vicianus)  an  example  associated  with   numerous  secondary 
nodules  in  the  liver  and  one  in  the  spleen.f 

It  is  well  known  that  accessory  adrenals  are  fairly  common, 
and  have,  in  many  instances,  been  detected  embedded  in  the 
cortex  of  the  kidney  beneath  its  capsule.  These  bodies  con- 
tain a  quantity  of  fat,  and  this  fact  has  led  many  writers  to 
describe  them  as  "  renal  lipomata."  When  sections  of  these 
supposed  fatty  tumours  are  submitted  to  ether  and  the  fat 
dissolved  from  them,  their  structural  identity  with  an  adrenal 
is  obvious  enough.  Ordinarily,  these  accessory  adrenals  are 
no  larger  than  a  cherry-stone,  but  now^  and  then  they 
become  large  and  dangerous  tumours,  and  by  pressure  induce 

*  Thornton,    Trans.  Path.    Soc,  vol.   xxxiv.    141,    and   Trans.    Clin.    Soc, 
vol.  xxiii.  150. 

f  Jotirnal  of  Anat.  and  Phys.,  vol.  xix.,  p.  458,  pi.  xxiii.,  fig.  7. 


100 


CONNECTIVE   TISSUE   TUMOUBS. 


destruction  of  the  kidney.  An  excellent  example  is  repre- 
sented in  Fig.  61,  which  was  removed  from  a  man  forty- three 
years  of  age.     Many  secondar}  nodules  ^\  ere  observed,  during 

Tlie  tiiinow 


Ureter 


Kidney. 


Pig.  61. — Eenal  tumour  originating  in  an  accessory  adrenal.     {After  Henry  Morris.*) 


the  operation,  in  the  liver.  There  was  also  a  fixed  hard 
nodule  in  the  left  temporal  region. 

Mr.  Morrisf  in  his  account  of .  this  interesting  case,  draws 
attention  to  the  analogy  of  this  kind  of  tumour  with  the  rare 
form  of  goitre  which  is  accompanied  by  secondary  deposits  in 
the  bone  and  viscera,  these  deposits  being  structural  repro- 
ductions of  the  thyroid  gland.     (See  page  243.) 

Clinical  Features. — In  describing  the  various  kinds  of  renal 
sarcomata,  incidental  references  have  been  made  to  most  of 
their  clinical  peculiarities.  Sarcomata  of  the  kidneys  in 
infants  are  so  well  known  that  their  clinical  recognition  is  a 
very  simple  matter. 

As  a  rule,  the  diagnosis  of  solid  renal  tumours  is  not  a 
matter  of  difficulty,  but  at  present  there  is  no  way  of  dis- 
tinguishing between  a  renal  sarcoma  and  a  tumour  arising  in 

*  Grawitz,  Yirchow's  "  Archiv,"  xciii.,  39. 
f  £rit.  Med.  Journal,  1893,  vol.  i.,  p.  2. 


SARCOMATA. 


101 


an  accessory  adrenal.  It  is  also  difficult  to  decide  between  a 
solid  renal  tiimour  and  one  arising  in  an  adrenal.  Clinical  ob- 
servation may  soon  render  this  probable,  for  it  has  been  noticed 
in  at  least  two  cases  (Thornton)  that  in  tumours  of  the  adrenal 
there  is  an  absence  of  htematuria,  whereas  in  all  cases  of  sohd 
tumours  of  the  kidney  in  adults,  whether  sarcomata  or  arising 
in  accessory  adrenals  lodged  in  its  cortex,  from  time  to  time 
the  urine  will  be  found  to  contain  blood, — sometimes  mere 
traces,  but  occasionally  it  will  be  abundant. 

Sarcoma  of  the  kidney  in  children  and  in  adults  runs  a 
rapidly  fatal  course.  In  children  the  duration  of  life,  after  the 
tumour  has  attained  such  a  size  as  to  be  obvious  clinically,  is 
rarely  longer  than  six  months.  In  adults  life  is  seldom  pro- 
longed beyond  eighteen  months.  The  malignancy  of  renal 
sarcomata  is  displayed  in  the  tables  on  pages  120  and  121. 

2.  Myo-sarcomata  of  the  Testis. — Tumours  composed 
mainly  of  spindle  cells  exhibiting  cross  striation  have  several 
times  been  found  in  connection  with  the  testis.  One  of  the 
earliest  and  most  carefully  described  cases  is  that  of  Neumann* 


Spermatic  cord. 

Epididymis. 

Testis. 

Tunica  vasrinalis. 


"  Portion  of  tumour  witliin 
the  tunica  vasinalis. 


Tlie  tumour. 


Fig.  62. — Myo-sarcoma  of  the  testis.    (After  Neumann.) 

(Fig.  62),  in  which  a  myoma  was  situated  at  the  lower  pole  of 
the  testis  of  a  child  three  and  a  half-years  old. 

Kibbertf  refers  to    three  specimens ;   of  these    two  were 


*  Virchow's  "  Archiv,"  bd.  ciii.   497. 

t  Virchow's  "Archiv,"  bd.  cxxx.  249.    This  paper  contains  a  complete  list  of 
references. 


102  CONNECTIVE   TTHSUf']    TUMOURH. 

removed   from   children   aged    thirteen    and   fourteen    years 
respectively ;  the  age  of  the  third  patient  is  not  stated. 

3.  Myo-sarcomata  of  the  Uterus  and  Vagina. — Tumours 
containing  striped  muscle  fibre  have  been  found  in  connection 
with  the  body  of  the  uterus,  neck  of  the  uterus,  and  vagina. 
One  of  the  most  remarkable  as  well  as  one  of  the  best  described 
cases  is  recorded  by  Pernice.*  In  this  instance  a  racemose 
tumour  fifrew  from  the  cervix  uteri  of  a  woman.  This  tumour, 
when  examined  microscopically,  was  found  to  contain  a  large 
number  of  spindle-shaped  cells,  which  were  nucleated,  and  ex- 
hibited a  transverse  striation  such  as  exists  in  myo-sarcomata. 
(Fig.  50.)  In  the  basal  parts  of  this  tumour  gland-like  spaces 
lined  with  cylindrical  or  with  cubical  epithelium  were  found. 

After  removal  the  tumour  quickly  recurred ;  it  was  removed 
a  second  time,  but  reappeared,  rapidly  infiltrated  the  uterus, 
forming  a  large  mass ;  death  speedily  ensued. 

When  the  recurrent  tumours  were  microscoped  no  striated 
spindles  were  found,  and  the  growth  had  all  the  characters  of 
a  spindle-celled  sarcoma. 

4.  Myo-sarcoma  of  the  Parotid  Gland. — Pruddenf  has 
described  a  tumour  situated  near  the  angle  of  the  mandible 
of  a  boy  seven  years  old.  The  tumour  contained,  in  addition  to 
round  and  spindle  cells,  numerous  striated  spindles  and  tubules 
lined  with  cubical  epithelium.  Its  resemblance  to  a  renal 
myo-sarcoma  was  thus  very  close. 

5.  Myo-sarcomata  of  Periosteum. — Zenker^  and  Bayer 
have  each  met  with  an  example  in  the  orbit ;  Targett  §  found 
one  on  the  scapula  of  a  child  six  months  old  ;  and  Marchand  || 
describes  one  which  grew  from  the  ischial  tuberosity  of  a 
boy  four  years  of  age.  It  is  also  singular  that  congenital 
lipomata  growing  from  periosteum  contain  striped  muscle 
fibre.     These  have  already  been  described  (page  13). 

There  has  been  much  speculation  as  to  the  mode  of  origin 
of  myo-sarcomata.  When  our  knowledge  of  them  was  limited 
to  those  which  occurred  in  the  kidney,  the  notion  that  they 

*  Virchow's  "Archiv,"  bd.  cxiii.  46. 
t  Am.  Jour.  Med.  Sci.,  1883. 
J  Vii'cliow's  "  Archiv,"  bd.  cxx. 

§  Trans.  Path.  Soc,  vol.  xliii.  157. 

II  Virchow's  "  Archiv,"  bd.  c.  p.  42. 


SARCOMATA.  103 

arose  in  detached  portions  of  the  mesoblastic  somites,  as 
suggested  by  Cohnheim,  found  favour  with  many ;  striped 
cells  in  tumours  of  the  testis  were  explained  as  arising  from 
the  muscular  tissue  of  the  gubernaculum.  Increased  observa- 
tions show  that  these  notions  are  untenable.  It  is  much  more 
reasonable  to  regard  the  presence  of  striated  cells  in  sarcomata 
as  due  to  the  similar  changes  in  the  tissue  that  give  rise  to 
hyaline  cartilage.  Muscle  belongs  to  the  connective  tissues, 
and  is  derived  from  the  same  tissue  as  that  which  furnishes 
cartilage  and  fat.  It  is  also  of  interest  in  relation  to  the  fre- 
quency with  which  chondro-sarcomata  arise  from  periosteum, 
that  myo-sarcomata  also  spring  from  this  membrane. 


104 

CHAPTER    XII. 

SARCOMATA    (continued). 

Lympho-sarcoma. — This  species  is,  by  many  writers,  regarded 
as  a  variety  of  the  round-celled  sarcoma.  As  lympho-sgircomata 
exhibit  a  very  characteristic  structure,  and  occur,  as  a  rule,  in 
very  definite  situations,  and  have  somewhat  special  clinical 
features,  it  is  desirable  to  separate  them  from  the  round-celled 
species.  These  tumours  occur  in  the  superior  mediastinum,  in 
the  subpleural  and  subperitoneal  connective  tissue,  at  the  base 
of  the  tongue,  in  the  larynx,  in  the  tonsil,  and  in  the  testis. 

In  considering  these  tumours,  the  overgrow^th  of  lymphoid 
tissue  in  lymph  glands  will  not  be  dealt  with ;  an  enlarged 
lymph  gland,  a  big  liver,  a  leukeemic  spleen,  or  a  parenchy- 
matous goitre,  are  not  tumours  in  the  sense  in  which  the 
term  is  employed  in  this  book. 

1.  Thoracic  Lympho-sarcomata.  —  The  most  frequent 
situation  for  a  lympho-sarcoma  is  the  posterior  mediastinum ; 
it  probably  starts  in  connection  with  a  lymphatic  gland,  and, 
growing  rapidly,  quickly  envelops  the  trachea  and  bronchi,  the 
aorta  and  other  large  vessels,  the  oesophagus,  and  large  nerve 
trunks.  The  tumour  extends  along  the.  branches  of  the 
bronchi  and  invades  the  interlobular  connective  tissue  at  the 
roots  of  the  lungs.  When  the  tumour  starts  in  the  superior 
mediastinum  it  descends  along  the  big  vessels  and  invests  the 
pericardium.  It  may  even  creep  along  the  sheaths  of  the 
vessels  to  the  heart  and  infiltrate  its  substance :  this  is  rare. 
Processes  of  the  tumour  may  find  their  way  along  the  sheaths 
of  the  big  vessels  and  appear  in  the  posterior  triangles  of 
the  neck. 

The  relation  of  a  mediastinal  lympho-sarcoma  to  the 
adjacent  structures  is  interesting.  For  instance,  the  large 
arterial  trunks,  though  embedded  in  the  tumour,  are  not  as 
a  rule  damaged  by  it;  the  thin-walled  veins  are  early 
compressed,  and  interference  with  the  venous  circulation 
is  a  marked  feature.  In  some  of  the  cases  infiltration 
of  the  walls  of  the  veins  takes  place,  and  processes  of  the 
tumour  project  into  their  channels. 


SARCOMATA. 


105 


The  bronclii  are  very  liable  to  be  damaged  by  a  lympho- 
sarcoma, for  the  tumour  moulds  itself  around  these  tubes,  and 
by  pressure  causes  them  to  be  narrowed ;  apart  from  this 
effect,  the  tissues  proper  of  the  tubes  become  eroded  as  well 
as  atrophied.  These  changes  not  only  induce  ditficulty  in 
respiration  by  restricting  the  admission  of  air,  but  the  com- 
pression of  the  vessels  accompanying  the  bronchi  leads  to 
changes  in  the  nutrition  of  the  pulmonary  tissue,  which  end 
in  pneumonia,  gangrene,  and  death. 

The  important  nerves  traversing  the  mediastinum,  the 
vagus  and  phrenic  nerves  especially,  are  often  involved  in  the 


Fig.  63. — Portion  of  a  mediastinal  lyniplio-saiconia,  to  show  tlie  manner  in  whicli  the 
tumour  extends  alonu;  tlie  bronclii  and  iiulmonary  vessels. 

tumour,  but  their  sheaths  are  rarely  invaded  by  the  cells ;  in 
some  instances  the  left  recurrent  laryngeal  nerve  is  compressed 
sufficiently  to  produce  severe  laryngeal  spasms  and  even 
paralysis  of  the  muscles  supplied  by  it. 


106  UONNEGTIVE    TfSS'UJ'J   TUMOURS. 

The  (Bsophagus  becomes  compressed  by  an  intrathoracic 
lympho-sarcoma,  but  dysphagia  is  not  so  prominent  a  symptom 
as  in  many  cases  of  intrathoracic  aneurysm. 

It  is  a  somewhat  remarkable  feature  of  lympho-sarcomata 
that  they  extend  to,  and  enclose,  neighbouring  lymph  glands 
without  affecting  them.  For  instance,  it  is  not  unusual,  in 
a  section  of  a  large  mediastinal  lympho-sarcoma,  to  find 
bronchial  lymph  glands,  fully  charged  with  pigment,  exposed 
on  the  cut  surface  of  the  tumour  and  embedded  in  its  substance. 
(Fig.  63.) 

2.  Abdominal  Lympho-sarcomata  occasionally  arise  in  the 
connective-tissue  planes  posterior  to  the  peritoneum ;  in  this 
situation  the  tumour  involves  the  abdominal  aorta,  and  is  con- 
ducted to  the  kidney  by  the  renal  vessels.  A  lympho-sarcoma 
sometimes  arises  in  the  perirenal  tissue  and  forms  large  lobu- 
lated  masses  enveloping  the  kidney.  My  own  observations 
indicate  that  abdominal  lympho-sarcomata  are  more  common 
in  children  than  adults. 

Lympho-sarcomata  sometimes  arise  in  the  connective  tissue 
between  the  pelvic  peritoneum  and  the  pelvic  fascia,  and  form 
large  lobulated  masses,  which  are  apt  to  involve  the  rectum. 
In  such  cases  large  secondary  deposits  are  formed  in  the  liver. 

3.  Lingual  and  Laryngeal  Lympho-sarcomata. — Between 
the  mouth  and  the  true  pharynx  there  exists  a  some- 
what remarkable  ring  of  lymphoid  tissue  which  is  worth 
some  consideration.  The  lateral  portions  of  this  ring  are 
indicated  by  the  tonsils ;  the  superior  segment  is  formed  by 
the  collection  of  adenoid  tissue  on  the  posterior  wall  of  the 
pharynx  near  the  roof,  known  as  the  pharyngeal  tonsil,  and 
the  inferior  segment  consists  of  a  collection  of  this  tissue  on  the 
posterior  third  of  the  tongue,  sometimes  referred  to  as  the 
lingual  tonsil;  extensions  from  it  run  downwards  into  the 
mucous  membrane  of  the  larynx.  This  circle  of  lymphoid 
tissue  is  the  source  of  lingual  and  laryngeal  lympho-sarcomata. 

Lingual  Lympho-sarcomata. — One  of  the  best  observed 
cases  is  recorded  by  Hutchinson.*  The  patient  was  a  man 
twenty-two  years  of  age.  The  tumour,  which  had  been  grow- 
ing half  the  patient's  life,  at  last  attained  such  a  size  as  to 
interfere  with  respiration  and  deglutition.     The  tongue  and 

*  Med.-Chir.  Trans.,  Iviii.  311. 


SAliCOMATA.  107 

tumour  were  removed.  The  mucous  membrane  covering  it 
was  nodulated  like  a  mulberry.  Two  years  later  there  was  a 
recurrence,  and  the  patient  died  quickly,  partly  from  pressure 
and  partly  from  exhaustion. 

Laryngeal  Lympho-sarcomata  are  very  rare  tumours,  and 
usually  take  the  form  of  outgrowths  from  the  laryngeal  mucous 
membrane.*  Bealef  recorded  fully  a  case  associated  with 
secondary  nodules  in  the  eyelid  and  cerebral  membranes. 

4.  Testicular  lympho-sarcomata  are  well-known  tumours, 
and  their  occurrence  in  this  organ  cannot  easily  be  explained. 
Many  of  these  tumours  are  described  as  small  round-celled 
sarcomata.  The  chief  facts  to  relate  concerning  them  is  that 
they  occur  in  lads  and  young  adults,  often  affect  first 
one  and  then  the  other  testicle  after  a  variable  interval,  dis- 
seminate very  rapidly,  and  speedily  cause  death. 

An  instructive  case  of  lympho-sarcoma  affecting  one 
testicle  and  subsequently  its  fellow  is  described  by  Hutchin- 
son. J  It  is  well  worth  perusal ;  the  patient  was  seventy  years 
of  age. 

*  Wolfenden  and  Martin,  "  Studies  in  Path.  Anat.,"  1888,  p.  26. 

t  Lancet,  1887,  vol.  ii.  749. 

X  Trans.  Path.  Soc,  vol.  xl.,  193. 


108 


CHAPTER    XIII. 

SARCOMATA  (continued). 

Melanosis  and  Melano-sarcoma. — In  the  majority  of  mammals 
there  are  certain  epithelial  and  fibrous  tissues  which  normally 
contain  pigment.  Among  pigmented  tissues  the  skin  and 
epithelial  layer  of  the  retina  hold  the  first  place.  In  skin  the 
pigment  is  chiefly  contained  in  the  deeper  layers  of  the  rete 
mucosum;  hence  hair  that  is  derived  from  the  cells  of  this 
layer  is  pigmented  also.  In  many  mammals  other  tissues 
contain  pigment,  such  as  the  mucous  membrane  of  the  roof 
of  the  mouth  of  the  dog,  and  the  blue  colouration  of  the 
vaginal  mucous  membrane  of  the  vervet  monkey. 

In  man  the  amount  of  pigment  in  the  skin  varies  greatly, 
so  that  we  may  pass  gradually  from  individuals  whose  skins 
are  intensely  black  to  others  who  have  no  trace  of  cutaneous 
pigment. 

It  is  a  noteworthy  fact  that  animals  with  no  pigment  in 
the  skin  also  lack  pigment  in  the  uveal  tract  of  the  eye- 
ball. A  familiar  example  of  this  is  the  white  rabbit  with 
pink  eyes.  Such  a  condition  is  termed  albinism,  and  colour- 
less animals,  or  albinos,  occur  among  all  classes  of  animals, 
vertebrate  and  invertebrate.  Excessive  development  of  black 
pigment  in  the  skin  is  known  as  melanism ;  this  is  much 
rarer  than  albinism. 

Abnormal  distribution  of  pigment  is  common ;  in  man  it 
gives  rise  to  the  condition  termed  leucoderma  when  it  affects 
the  skin,  and  unequal  distribution  of  pigment  in  the  retina  is 
known  as  retinitis  pigmentosa.  Irregular  patches  of  black  in 
the  skins  of  horses  cause  them  to  be  described  as  piebald,  and 
when  disseminated  in  small  dots  and  irregular  tracts  they  are 
said  to  be  grey. 

In  the  white  races  of  men  the  pigment  granules  are  almost 
entirely  confined  to  the  cells  of  the  rete  mucosum,  but 
when  the  pigmentation  is  very  marked  it  will  be  found  dis- 
tributed in  the  other  tissues  of  the  skin.  The  pigment,  or 
melanin  as  it  is  called,  lies  within  the  cells  either  in  the 
form  of  black  or  brown  granules,  or  they  may  be  uniformly 


8ABG0MATA. 


109 


stained  by  it.  As  to  the  source  of  the  pigment  nothing 
is  known. 

Melanosis  is  sometimes  produced  by  parasites.  This 
variety  of  melanism  is  rarely  seen  in  man,  but  is  fairly  frequent 
in  other  animals.     An  example  is  depicted  in  Fig.  64. 

Pigmentation  in  this  form  is  not  uncommon  in  the 
lungs  of  mammals,  but  it  must  not  be  confounded  with  the 


Fig.  04. — Anterior  portion  of  a  dace  ;  each  black  spot  contains  a  central  white  dot 
representing  an  encysted  parasite. 

irregular  black  patches  so  common  in  the  lungs  of  those 
who  dwell  in  densely  populated  and  smoky  toAvns.  Small 
nodules  surrounded  by  a  zone  of  intensely  black  pigment  are 
not  uncommon  in  the  skins  of  dogs  ;  the  central  nodules 
usually  contain  an  encysted  parasite. 

Pathological  pigmentation  in  its  most  serious  forms  is  found 
in  connection  with  tumours  arising  in  the  skin  or  within  the 
eyeball.     Melanotic  tumours  occur  in  two  genera  : — ■ 

1.  Melano-sarcoma. 

2.  Melano-carcinoma. 

1.  Melano-sarcomata — It  was  formerly  the  custom  to 
describe  all  varieties  of  melanotic  tumours  as  cancers.  Later, 
when  the  histological  distinctions  between  sarcoma  and  cancer 
were  more  accurately  defined,  it  was  found  that  the  majority  of 
tumours  containing  black  pigment  were  structurally  sarcomata. 
Recent  careful  researches,  of  which  some  details  will  be  ffiven 
afterwards,  establish  beyond  any  doubt  that  some  melanomata 
are  cancers. 


no  (JONNECTIVE   TISSUE   TUMOURH. 

In  these  tuinours,  whether  sarcomata  or  cancers,  the 
amount  of  pigment  varies  greatly ;  in  some  it  is  so  Httle  that 
the  tumours  on  section  present  merely  a  brown  colouration, 
whilst  in  others  it  may  be  so  abundant  that  they  are  of  the 
deepest  black.  The  pigment  particles  are  lodged  in  and 
among  not  only  the  characteristic  cells  of  the  tumour,  but  in 
and  among  those  of  its  fibrous  matrix,  and  even  in  the  walls 
of  its  vessels.  It  is  also  worth  mention  that  the  primary 
tumour  may  contain  very  slight  traces  of  pigment,  sometimes 
so  slight  as  even  to  raise  a  doubt  whether  it  should  be  called 
melanotic ;  yet  the  secondary  growths  and  the  lymph  glands 
infected  by  it  will  be  of  an  inky-black  colour.  The  intense 
blackness  of  the  secondary  deposits  leads  to  their  ready 
recognition,  and  doubtless  accounts  for  the  belief  that  this 
species  becomes  more  widely  disseminated  than  other  malignant 
tumours  ;  but  an  equally  wide  distribution  of  secondary  nodules 
in  unpigmented  tumours  will  sometimes  be  found  when  the 
organs  are  submitted  to  a  rigorous  search. 

Primary  Melano-sarcomata  of  the  Skin. — Two  varieties 
of  melano-sarcoma  occur  in  the  skin.  The  most  frequent  has 
its  origin  in  pigmented  moles  (Fig.  65) ;  the  rarer  variety 
arises  in,  or  near,  the  matrix  of  the  nail  of  a  finger  or  toe. 

Melano-sarcomata  occurring  in  moles  differ  from  other 
melanomata  in  that  the  cells  are  collected  in  alveoli.  It  is 
pointed  out  in  the  chapter  on  moles  that  the  tissue  forming 
the  base  of  a  mole,  as  a  rule,  presents  an  alveolar  disposition ; 
this  structural  peculiarity  comes  out  very  strongly  when  a 
mole  is  the  seat  of  a  melanoma. 

A  pigmented  mole  may  remain  quiescent  throughout  a 
very  long  life  and  never  cause  the  least  inconvenience;  in 
other  instances,  fortunately  rare,  as  life  advances  the  mole 
ulcerates,  perhaps  bleeds  freely,  and  may  even  become  partially 
healed ;  but  coincident  with  the  onset  of  ulceration  the  adjacent 
lymph  glands  enlarge,  become  charged  with  pigment  and 
sarcomatous  tissue,  spaces  filled  with  inky  fluid  form  in  them, 
and  finally  the  overlying  skin  ulcerates.  The  infection  may 
not  proceed  further  than  this ;  recurrent  hemorrhages  from 
the  fungating  glands  or  a  furious  bleeding,  should  a  large 
vein  or  artery  become  broached  by  ulceration,  carries  off  the 
patient.     In  many  cases  the  morbid  material  is  disseminated 


SARCOMATA. 


Ill 


into  distant  parts,  secondary  knots  form  in  the  liver,  lung, 
kidney,  or  brain,  and  death,  arises  from  interference  with  the 
functions  of  these  organs. 

In  other  cases  the  mole,  instead  of  ulcerating,  is  observed 


Fig.   (35. — Pigmented  mole   which  ulceiateil  and  infected  the  inguinal  lymph  glands  ; 
the  patient  \^as  sixty  tl^  e  yeaib  of  age. 

to  become  more  prominent,  and  linally  forms  a  tumour  of 
some  size  standing  out  prominently  from  the  skin.  In  due 
course   the  lymph  glands,  in  anatomical   relation    with   the 


112 


CONN  EC  TI VE   TIH8  UE   TUMO  URH. 


part  from  which  the  tumour  arose,  enlarge,  and  secondary 
deposits  occur  in  the  viscera,  bones,  or  skin. 

It  does  not  necessarily  follow  that  in  all  cases  of  melano- 
mata  occurring  in  moles  secondary  deposits  are  formed  in  the 
viscera.  In  some  cases,  which,  however,  are  very  rare,  the 
tumour  seems  to  become  mainly  a  source  of  pigment, 
large  quantities  of  which  enter  the  circulation  to  be  dis- 
charged with  the  urine  in  which  it  is  recognised  as  melanin. 
Exceptionally  the  skin  will  assume  a  dusky  tint,  and  in  one 
instance  in  which  a  woman  with  a  melanoma  died  immediately 
after  a  menstrual  period,  I  found  the  corpus  luteum  and  some 
distended  follicles  tilled  with  an  inky  fluid. 

Digital  Melanomata. — Melanosis  in  connection  Avith  the 
fingers  and  toes  assumes  two  forms :  it  may  occur  as  a  deep 
pigmentation  of  the  skin,  usually  in  the  immediate  neighbour- 
hood of  the  nail,  often  involving  the  matrix,  and  even  the  nail 
itself ;  or  a  small  pigmented  nodule  will  arise  in  the  nail  matrix 
or  in  the  adjacent  skin.  These  nodules  quickly  ulcerate,  and 
dissemination  follows.  In  some  of  these  nodules  the  pigment 
is  very  scanty — indeed  in  some  cases  it  is  only  discovered  with 
the  microscope ;  yet  secondary  nodules  of  an  intense  black 
colour  will  arise  in  the  various  organs  and  tissues. 

The  hallux  is  the  digit  most  prone  to  be  attacked  by 
melanomata,  and  several  examples  have  been  carefully  recorded, 
most  of  the  patients  being  women.  These  cases  are  arranged 
in  the  following  table  : — 


Fergusson    . 

M. 

36 

Hallux  . 

Lancet,  1857,  i.,  p.  290. 

Hutchinson. 

F. 

60 

Hallux  . 

Trans.  Path.  Soc,  Vol.  viii. 

p.  404. 

Nunii  . 

F. 

50 

Fifth  Finger. 

Ibid.,  Vol.  xxxi.,  p.  299. 

Lediard 

F. 

40 

Index  Finger 

Ibid.,  Vol.  xxxix.,  307. 

Bowlby 

F. 

55 

Hallux  . 

Ibid.,  Vol.  xli.,  314. 

Intra-ocular  Melanomata. — Pigmented  tumours  arising 
within  the  eyeball  belong  to  two  genera,  sarcoma  and  car- 
cinoma. Of  these,  the  melano-sarcoma  is  very  much  more 
frequent  than  the  melano-carcinoma. 

Melano-sarcomata  may  arise  from  any  part  of  the  uveal 
tract — that  is,  from  the  pigmented  connective  tissue  in 
relation  with   the  iris,  the  ciliary  body,  or  the  choroid.      A 


SARCOMATA.  113 

melano-sarcoma  of  tlie  iris  is  excessively  rare,  and  it  is  probably 
ten  times  more  common  in  the  choroid  than  in  the  ciliary 
body.     (Fig.  66.) 

In  structure  the  sarcomatous  ele- 
ments may  be  round-celled,  spindle- 
celled,  or  mixed-celled,  the  size  of  the 
cells  varying  greatly  in  different  speci- 
mens. 

They  occur  during  youth,  cases  having 
been  observed  as  early  as  the  fifteenth    ^'-  'thellveurt^^'cr™^  "' 
year ;  but  the  liability  increases  with  age. 
By  far  the  greater  number  of  recorded  cases  has  been  met 
with  between  the  age  of  forty  and  sixty  years,  and  a  case  has 
been  reported  as  late  as  the  eighty-fourth  year. 

The  amount  of  pigment  in  intra-ocular  melanomata  varies 
greatly ;  in  some  specimens  it  is  so  abundant  that  the  tumour 
is  coal-black;  in  others  it  is  only  sufficient  to  impart  a  grey 
tint.  Occasionally  the  pigment  is  so  irregularly  distributed 
that  some  parts  of  it  are  colourless. 

The  tumour  remains  for  a  time  restricted  to  the  interior  of 
the  globe,  but  it  tends  to  escape  therefrom  in  three  directions: 
(a)  along  the  course  of  the  vente  vorticosa^,  and  appears  outside 
the  sclerotic  in  the  situations  where  these  veins  emerge ;  (h) 
the  presence  of  the  tumour  leads  to  an  increase  in  the  intra- 
ocular tension,  and  finally  sloughing  of  the  cornea;  (c)  the 
growth  may  invade  the  optic  nerve. 

Melano-sarcomata,  like  all  species  of  sarcomata,  are  very 
apt  to  recur  after  removal,  and  to  become  disseminated.  The 
most  frequent  situation  in  which  to  find  secondary  deposits 
is  the  liver  (Fig.  67) ;  but  any  organ  may  contain  them,  even 
the  bones.  It  is  surprising,  considering  that  the  eyeball  is  so 
near  to,  and  in  such  close  relation  with  the  brain,  by  so  large 
a  nerve-trunk  as  the  optic  nerve,  that  it  should  be  so  rarely 
implicated.  It  is  a  fact  that  when  the  brain  is  the  seat  of 
deposit  it  is  excessively  rarely  the  result  of  extension  along 
the  nerve.  The  amount  of  dissemination  varies  greatly ;  in 
some  cases  secondary  knots  occur  in  almost  every  organ ;  in 
others  they  will  be  limited  to  the  liver.  The  lymph  glands 
adjacent  to  the  orbit  are  rarely  infected.  It  is  curious  that  in 
most  cases  death  results  more  often  from  the  secondary  growths 
I 


114 


CONNECTIVE    TIH8UE    TUMOUIiH. 


involving  important  organs  than  from  the  local  effects  of  the 
primary  tumonr. 

An  excessively  rare  complication  of  melanotic  tumours  is 


Fig.  67. — Secondary  nodules  of  melano-sarcoma  in  tlie  liver. 

pigmentation  of  the  skin.  An  admirable  example  of  this  has 
been  recorded  by  Dr.  Wickham  Legge*  (Plate  II.).  The  patient, 
a  shoemaker,  had  the  left  eye  enucleated  at  the  Ophthalmic 
Hospital,  Moorfields,  when  he  was  fifty-eight  years  of  age,  for 

*  Trans.  Path.  Soc,  vol.  xxxv.,  p.  367. 


PLATE  II. — Melanosis  of  the  Skin,  secondary  to  Melano-sarcoma  of  the 
Uveal  Tract.     (WickhaM  Legye.) 


SARCOMATA.  115 

melanotic  spindle-cellecl  sarcoma.  He  died  twenty  months 
later  in  St.  Bartholomew's  Hospital,  with  secondary  nodules  in 
various  organs,  particularly  the  liver.  The  most  remarkable 
feature  in  the  case  was  that  six  months  before  death  his  face 
began  to  assume  a  dark  appearance,  and  on  his  admission  into 
the  hospital  the  appearance  of  his  face  strongly  suggested 
argyrism,  but  the  most  careful  interrogatories  failed  to  bring 
out  any  evidence  that  the  man  had  ever  taken  silver  salts.  In 
this  case  it  is  worthy  of  note  that  the  urine  gave  a  deep  brown 
colour  with  hydrochloric  acid  and  chloride  of  calcium ;  the 
colour  on  standing  deepened  to  black.  No  dark  granules  were 
ever  found  in  the  urine.  At  the  post-mortem  examination  an 
abundance  of  dark-coloured  fluid  escaped  from  the  belly. 

In  some  rare  cases  pigmentation  of  the  skin,  secondary  to 
melanomata,  assumes  the  form  of  discrete  circular  spots, 
varying  from  two  to  four  mm.  in  diameter.  I  have  counted 
three  thousand  of  these  spots  in  one  patient. 

2.  Melano-carcinomata.^Several  writers  who  have  devoted 
attention  to  intra-ocular  growths  describe  some  of  the  pig- 
mented tumours  as  carcinomata,  using  the  term  in  the  definite 
sense  with  which  it  is  employed  in  this  work.  Much  new  light 
has  been  thrown  on  this  question  by  the  interesting  investiga- 
tions of  Treacher  Collins.*  This  ophthalmologist  has  demon- 
strated the  existence  in  the  ciliary  body,  in  the  space  extending 
from  the  root  of  the  iris  to  the  ora  serrata,  of  a  number  of  small 
tubular  processes  composed  of  epithelial  cells  with  their  free 
ends  projecting  towards  the  ciliary  muscle.  Collins  succeeded 
in  demonstrating  the  existence  of  these  processes  by  ingeniously 
depriving  the  cells  of  their  pigment  by  bleaching ;  he  regards 
these  processes  as  glands,  which  secrete  the  aqueous  humour. 
The  ciliary  glands  are  interesting  in  connection  with  melano- 
carcinoma,  for  Collins  discovered  among  the  intra-ocular 
tumours  preserved  in  the  museum  of  the  Moorfields  Hospital, 
two  examples  from  the  ciliary  body  which  were  epithelial  in 
character.  In  examining  them  he  adopted  the  bleaching 
method  to  which  reference  has  already  been  made. 

The  duration  of  life  in  patients  with  intra-ocular  melano- 
mata rarely  extends  beyond  three  years.  A  careful  analysis  of 
a  large  number  of  cases  shows,  however,  that  in  many  instances 

*  Trans.  Ophthal.  Soc,  London,  vol.  xi. 


116  CONNECTIVE    TISHUE    TJJMOUEH. 

life  may  be  indefinitely  prolonged  by  early  removal  of  the  glolje, 
and  cases  are  known  in  which  patients  have  been  reported 
alive  and  well  live,  six,  eight,  nine,  sixteen  and  eighteen  years 
after  the  operation.  In  the  majority  of  cases  that  recur,  the 
recurrence  takes  place  within  three  years  of  the  operation. 
Collins  and  Lawford,*  calculating  cases  in  which  recurrence 
does  not  take  place  within  three  years  of  operation  as  recovery, 
come  to  the  conclusion,  from  an  analysis  of  seventy-nine  cases 
of  which  they  were  able  to  obtain  complete  records,  that  the  rate 
of  recovery  is  twenty-five  per  cent.,  but  they  point  out  that 
patients  have  died  from  recurrence  or  secondary  deposits  after 
a  much  longer  interval  than  three  years.  J.  Hutchinson,  junr.,t 
has  mentioned  a  case  in  which  dissemination  was  deferred  for 
eleven  years  after  an  eye  had  been  excised  for  melanoma. 

Melano-sarcomata  in  horses  are  of  fairly  common  occur- 
rence ;  the  regions  most  affected  are  the  tail  and  the  parts 
about  the  anus,  where  they  form  large  mushroom-like  excre 
scences,  with  little  disposition  to  ulcerate.  The  tumours  in  some 
cases  attain  large  proportions,  and  have  been  known  to  weigh 
forty,  fifty,  and  even  sixty  pounds.  When  a  large  tumour  grows 
from  a  horse's  tail  it  becomes  a  great  encumbrance,  which 
the  veterinarian  removes  by  amputation.  It  occasionally  hap- 
pens that  in  the  operation  a  portion  of  the  tumour  is  left 
behind,  and  its  cut  surface  heals  like  other  tissues.  These 
pigmented  tumours  are  very  prone  to  disseminate,  and 
secondary  nodules  occur  in  almost  all  the  viscera ;  yet,  in  spite 
of  this,  melano-sarcoma  does  not  appear  to  be  such  a  malignant 
affection  in  horses  as  in  men. 

Although  most  common  in  grey,  it  also  occurs  in  white, 
and  occasionally  in  black  horses,  and  it  certainly  occurs  in  cows. 
Next  to  the  anus  and  tail,  the  udder  is  the  most  frequent  seat 
of  the  primary  tumour,  and  it  may  spring  up  in  the  sub- 
cutaneous connective  tissue  in  any  part  of  the  trunk.  Horses 
may  be  attacked  at  any  age  from  four  years  upwards.  In 
structure  melano-sarcoma  of  the  horse  resembles  a  hard 
uterine  myoma  rather  than  a  sarcoma.  In  these  animals 
melano-sarcoma  of  the  uveal  tract  is  very  rare. 

*  "  Notes  on  One  Hundred  and  Three  Cases  of  Sarcoma  of  the  Uveal  Tract." 
E.  Lond.  Ophth.  Hosp.  Eep.,  Dec,  1891. 
t  Brif.  Jlled.  Journal,  1893,  vol.  i.,  291. 


117 


CHAPTER    XIV. 

SARCOMATA  (concluded). 

Treatment. — Although  the  principle  involved  in  the  treatment 
of  sarcomata  is  expressed  in  the  following  brief  sentence — 
early  and  complete  removal  when  they  occur  in  accessible 
positions — nevertheless  the  mode  of  effecting  this  varies 
according  to  the  organ  involved.  In  a  few  situations,  such  as 
the  mediastinum,  basal  parts  of  the  brain,  skull-base,  bodies 
of  vertebrae,  the  pelvic  bones  and  the  liver,  the  successful 
removal  of  a  sarcoma  is  an  impossibility.  Occasionally,  in 
other  parts  of  the  body,  the  tumour  grows  rajDidly  and  in- 
filtrates so  wide  an  area  of  tissue  that  its  extirpation  would 
involve  such  an  extensive  operation  as  to  render  recovery 
extremely  doubtful  or  impossible. 

When  there  is  evidence  of  dissemination  it  is  then  too 
late  to  interfere,  unless  the  primary  tumour  is  a  source  of 
such  pain  and  discomfort  that  its  removal  is  demanded  merely 
to  relieve  the  patient. 

The  means  employed  in  the  operative  treatment  of  sarco- 
mata (unfortunately  nothing  short  of  this  is  of  the  least  use) 
vary  according  to  the  seat  of  the  tumour.  There  are  a  few 
definite  rules  followed  by  surgeons  in  this  matter. 

Bones. — In  the  case  of  sarcomata  of  the  limb  bones  it  is 
usual,  except  in  the  case  of  myeloid  tumours,  to  amputate  the 
limb  at  such  a  point  as  shall  remove  the  affected  bone. 

For  instance,  if  the  sarcoma  involve  the  tibia  or  fibula, 
amputation  should  be  performed  at  the  knee  joint  or  lower 
third  of  the  thigh.  In  the  case  of  the  radius  or  ulna  the 
limb  should  be  removed  at  the  elbow  or  lower  third  of  the 
arm.  When  the  humerus  is  the  affected  bone,  it  should  be 
removed  at  the  shoulder  joint,  or  even  the  scapula  removed 
with  it  when  the  tumour  implicates  the  upper  end  of  the 
bone.  In  the  case  of  the  femur  the  usual  practice  is  to 
amputate  at  the  hip  joint  for  periosteal  sarcoma  of  the  lower 
third  of  this  bone  ;  when  the  tumour  is  central  the  operation 
ma}^  be  carried  out  in  the  upper  third  of  the  thigh.  When 
the -tumour  involves  the  upper  half  of  the  femur,  amputation 


118  CONNECTIVE    TISSUE    TUMOUTiS. 

nasiy  sometimes  be  carried  out :    but,  as   a  rule,  it  is  not  a 
proceeding  to  urge  upon  the  patient. 

Myeloid  Sarcomata  do  not  demand  such  vigorous  treat- 
ment as  the  other  species.  In  the  case  of  the  upper  Hmb  it  is 
only  necessary  to  excise  the  affected  end  of  the  bone.  This 
was  demonstrated  by  Morris.*  In  1876  this  surgeon  excised 
the  lower  end  of  the  right  radius  and  lower  fourth  of  the 
ulna.     (Fig.  68.)     Sixteen  years  later  the  patient  was  free  from 


Fig.  6S. — Forearm  of  a  woman  four  years  after  excision  of  the  lower  fourtli  of  the  ulna  and 
the  radius  for  a  myeloid  sarcoma  of  the  radius.     {After  Henry  Morris.) 

recurrence,  and  the  hand  was  so  useful  that  I  have  seen  her 
hold  a  needle  with  the  thumb  and  forefinger.  Lucasf  followed 
this  example  and  resected  the  lower  end  of  the  left  ulna  in  a 
woman  twenty-nine  years  of  age.  Ten  years  later  she  was 
free  from  recurrence.  In  1890  I  excised  the  outer  third  of  the 
clavicle  I  for  a  myeloid  sarcoma  of  the  acromial  end  of  this 
bone  ;  three  years  later  the  patient  was  in  good  health  and  free 
from  recurrence.  Clutton§  excised  the  upper  three  inches  of 
the  radius  for  myeloid  sarcoma  in  a  man  twenty-eight  years 
of  age  ;  the  patient  recovered  with  free  movement  of  the  elbow. 
The  man  survived  the  operation  eighteen  months,  then  died 
of  kidney  disease  (albuminuria).     There  was  no  recurrence.  || 

The  maxilla  is  frequently  removed  when  involved  by  a 
sarcoma.  In  exceptional  cases  both  maxillae  have  been  ex- 
cised at  one  operation.  In  the  case  of  the  mandible  it  is  usual 
to  remove  the  affected  half ;  in  a  large  proportion  of  cases  the 
surgeon  is  content  to  leave  the  ramus  of  the  bone,  unless  it  be 
implicated. 

*  Trans.  Clin.  Soc,  vol.  x.  138,  xiii.  155,  and  xxii.  367. 

1"  Trans.  Clin.  Soc,  vol.  x.  135,  and  xxii.  366. 

J  Trans.  Clin.  Soc,  vol.  xxiv.  12. 

§  Museum  Cat.,  St.  Thomas's  Hospital,  Part  i.,  p.  105,  No.  659. 

II  See  Mott's  case,  foot-note,  p.  125. 


SARCOMATA.  119 

In  cases  of  large  sarcomata  growing  in  situations  where 
removal  is  an  impossibility,  ligature  of  tlie  main  artery 
supplying  it  has  been  practised.  Treves  *  has  recorded  an 
encouraging  case  of  this  kind.  A  lad  sixteen  years  of  age  had 
a  large  rapidly-growing  sarcoma  of  the  buttock.  Ligature  of 
the  left  internal  iliac  artery  was  followed  by  rapid  diminution 
of  the  tumour.  Ten  months  later  it  began  to  grow  again, 
and  the  patient  died  fourteen  months  after  the  ligature  of 
the  artery. 

Muscles. — It  is  the  usual  practice  to  dissect  out  if  possible 
the  whole  of  the  affected  muscle.  This  operation  has  been 
carried  out  in  a  few  instances,  but  in  many  cases,  such  for 
instance  as  the  peroneus  longus  and  the  gracilis,  it  is  easy 
enough  to  remove  the  bellies  of  the  muscles,  but  the  tendons 
offer  greater  difficulty.  When  several  muscles  are  implicated, 
or  when  there  is  recurrence,  it  is  safer  to  remove  the 
limb  above  the  origins  of  the  affected  muscles  if  this  is 
practicable. 

Secreting  Glands. — In  the  case  of  the  parotid  and  sub- 
maxillary glands,  sarcomata,  especially  those  in  which  cartilage 
is  abundant,  will  occasionally  shell  out,  but  in  many  the 
periosteum  of  the  mandible  is  implicated.  It  is  then  necessary 
to  remove  freely  the  involved  portion  of  this  bone. 

Genital  Glands. — Castration  is  the  proper  treatment  for 
sarcoma  of  the  testis  so  long  as  it  is  possible  to  remove  the 
gland  above  the  disease.  When  the  cord  is  extensively  in- 
volved operative  interference  is,  as  a  rule,  very  useless. 

In  the  case  of  the  ovary  it  is  often  difficult  to  decide  be- 
tween a  cyst,  a  sarcoma,  or  a  dermoid  of  moderate  dimensions ; 
the  presence  of  ascites  is  always  a  suspicious,  but  by  no  means 
absolute,  sign  of  malignancy.  Ovariotomy  has  been  many 
times  performed  for  sarcoma,  and  should  always  be  advised  in 
adults  so  long  as  there  is  no  evidence  of  dissemination.  In 
children  it  is  a  useless  proceeding.     (See  page  123.) 

Eyeball. — Early  removal  of  the  eyeball  for  an  intra-ocular 
sarcoma  is  the  mode  of  treatment  that  should  be  earnestly 
urged  upon  the  patient. 

Skin. — In  the  case  of  skin,  sarcomata  should  be  freely  ex- 
cised, and  the  adjacent  lymph  glands  removed  at  the  same  time. 

"^  Trans.  Clin.  Soc,  vol.  xxv.  2i9. 


120 


UONNEGTIVE    TfHHUE    TUMOURS. 


Kidney. — It  has  been  customary  in  previous  writings  on 
the  operative  treatment  of  renal  sarcomata  to  inckide  in  one 
table  all  cases  irrespective  of  the  ages  of  the  patients ;  it  was 
pointed  out  in  describing  sarcomata  of  the  kidneys  that  they 
occur  at  two  periods  of  life — viz.,  during  infancy  and  in  adult  life, 
the  period  of  youth  being  almost  exempt  from  these  tumours. 

This  fact  comes  out  in  a  very  striking  manner  in  the 
accompanying  tables,  where  sarcomata  of  infants  are  arranged 


OPERATIONS  FOR  RENAL  SARCOMATA  IN  CHILDREN 
UNDER  SIX  YEARS  OF  AGE. 


Reporter. 

Age. 

Result  of 
Operation. 

Reference. 

Oilier 

4^  vrs. 

D.          .         .         . 

Bevue  de  Chir,  1883,  898. 

Jessop 

2|  yrs.  . 

R.  Recurrence  and 
death  in  9  mths. 

Lcmcet,  1877.     A^ol.  i.  889. 

Kocher 

2.^  yrs. 

D.          .         .         . 

JJent.Zeitsch.fiir  Chir.,  Bd.  ix. 
312. 

Czerny 

11  mths. 

D.          .         .         . 

Beut.  Med.  Wochemeh.,  1881, 
No.  xxxi.  422. 

Hueter 

4  yrs.    . 

D.          .         .         . 

Lent.  Zeitsch.  fur  Chir.,  Bd.  ix. 

527. 
Trans.  Path.   Soc,  Yol.  xxxvi. 

Croft 

2  yrs.    . 

R.  Recurrence  and 

death  within  a  yr. 

274. 

Grodlee 

1  yr.  10  niths. 

R,  Recurrence  and 
death  in  6  mths. 

Trans.  Clin.  Soc,  Yol.  xviii.  31. 

Meredith    . 

4  yrs.    . 

D.          .         .         . 

Brit.  Med.  Journ.,  1884.  Yol.  ii. 
863. 

Owen 

10  mths. 

D.          .         .         . 

Cat.Mus.  St.  MarifsHptL,  1891. 

Pughe 

2  yrs,  4  mths. 

D.          .         .         . 

Trans.  Path.  Soc,  Yol.  xxxi. 

Alsberg 

5  yrs.    . 

R.  Recurrence, 

Deut.   Med.    Wochensch,    1887, 

death  in  11  weeks 

873. 

Rawdon      . 

1  jT.  9  mths. 

D.          .         .         . 

Liverpool  Med.- Chir.  Jour.,  Yol. 
iii.,  252. 

Taylor 

1  yr.  8  mths. 

D 

Am.  Jour.  Med.  Sci.,  1887,  470. 

Brokaw 

3  yrs.  8  mths. 

R.  Rec.  and  death 
2  mths.  later. 

Phil.  Med.Neivs,  1891,  Iviii.  313. 

Author 

1  Yr.  6  mths. 

D.          .         .         . 

Unpublished. 

A.  Czerny . 

31  yrs. . 

D.                   .         . 

Arch,  flir  Kinderkranh.,  Bd.  xi. 
247. 

Konig 

6  yrs.    . 

R.  Rec,    death   in 

5  mths. 

Konig 

2  yrs.    . 

R.  Rec.  in  3i  mths. 

1   Beut.   Zeitsch.  filr  Chir.,  Bd. 

Konig 

I  yr.  3  mths. 

D.          .      ". 

/       xxix.  590. 

Fischer 

4i  JTS 

R.  Rec.  and  death 

in  4  mths. 

J 

"Walsham  . 

10  mths. 

R.  Rec.  within    12 

Brit.  Med.  Journal,  1893,  Yol.  i. 

mths. 

694. 

The  facts  expressed  in  the  above  Table  amount  to  this  : — There  were  21 
operations,  with  9  recoveries  and  12  deaths.  Of  those  which  recovered  from  the 
operation,  all  were  dead  within  a  year. 


SARCOMATA.  121 

OPERATIONS   FOE   RENAL   SARCOMATA   IN   ADULTS. 


Reporter. 

i 

Result  of 
Operation. 

Reference. 

<j 

Barker    . 

21 

D 

Med.-Ckir.  Trans.,  Ixiii.  191. 

Thornton 

25 

D.    .         . 

3Ied.-Chir.  Trans.,  Ixxii.  313. 

Thornton 

53 

R.  Died  1  year  later 
-with  recurrence 

J)               )> 

Morris     . 

51 

D 

Brit.  iVed.  Jotirn.,  1893,  Vol.  i.  p.  2. 

Morris     . 

70 

D 

JJ                               J> 

Morris     . 

55 

R.  Died  3  mths.  later 

)  ?                               ?  J 

Morris     . 

35 

R.  Died  3  mths.  later 
with  recurrence. 

Morris     . 

43 

R.  Died  within  a  year. 

)>                            M 

McCarthy 

37 

R.  Died  a  few  weeks 
later  with  rec. 

Trans.  Path..  Soc,  Vol.  x.xxvii.  295. 

Author    . 

54 

D 

Unpublished. 

Skene  Keith    . 

61 

D 

Edin.  Med.  Journ.,  Oct.  1886,  p.  351. 

Adams    . 

39 

R.  Died  in  six  weeks. 

Med.  Times  and  Gaz. ,  1882,Vol.  ii.  678. 

Whitehead 

46 

D."    . 

Brit.  Med.  Journ.,  1881,  Vol.  ii.  741. 

Sp.  Wells 

58 

D 

Med.-Chir.  Trans. ,\6\..  Ixvi.  305. 

In  this  Table  there  are  14  operations,  with  6  recoveries  and  8  deaths.  Of 
those  who  recovered,  all  were  dead  from  recurrence  within  the  year. 

in  one  table  and  sarcomata  of  adults  in  another.  Many  of  the 
tumours  in  adults  were  recorded  as  examples  of  "  encephaloid," 
a  term  which  has  no  meaning  for  the  pathologist,  and  for  the 
surgeon  has  probably  the  same  significance  as  sarcoma. 

It  is  necessary  to  mention  that  Ris*  has  reported  a  case  in 
which  Kronlein  of  Zurich  excised  a  kidney  from  a  woman 
fifty-six  years  of  age  for  a  tumour,  described  by  Klebs  as  an 
adeno-sarcoma ;  the  patient  was  alive  and  well  five  years  after 
the  operation. 

Nephrectomy  for  renal  sarcoma  in  children  is  absolutely 
unavailing,  and  is  fast  falling  into  disfavour.  The  excision  of 
a  sarcomatous  kidney  in  adults  is  occasionaUy  a  measure  of 
necessity,  on  account  of  the  great  pain  and  distress  it 
induces.  It  is  curious  that  renal  sarcomata  cause  no  pain 
when  they  occur  in  young  children. 

It  is  as  yet  impossible  to  speak  definitely  in  regard  to  the 
results  of  excision  of  adrenal  tumours  until  more  of  these 
cases  have  been  accurately  studied.  At  present  there  is  good 
reason  to  believe  that  they  are  less  malignant  than  renal 
sarcomata. 

*  Bruns,  Beitrdge,  bd.  vii.,  146. 


122  GONNEGTIVF.    TISSUE    TUMOURS. 

The  Results  of  the  Operative  Treatment  of  Sarcomata. — 

A  comprehensive  study  of  this  question  indicates  that  the 
results  of  operations  for  sarcomata  are  influenced  by  the 
situation  as  well  as  by  the  nature  of  the  tumours. 

It  is  a  somewhat  remarkable  fact  that  the  two  most  deadly 
situations  in  which  sarcomata  grow  are  the  periosteum  of  the 
femur  and  the  maxilla.  In  the  majority  of  cases  in  which 
amputation  is  performed  for  round-  or  spindle-cellecl  sarcomata 
of  the  femur,  the  patients  die  within  a  year  of  the  operation. 
Many  of  them  succumb  at  the  end  of  three  months,  the  fatal 
result  being  due  in  most  patients  to  secondary  deposits  in 
the  lungs. 

In  the  case  of  the  maxilla,  life  is  rarely  prolonged  beyond 
a  year ;  the  patients  in  a  few  instances  die  from  rapid  and 
extensive  recurrence,  or  from  broncho-pneumonia,  rarely  from 
dissemination. 

In  other  bones  far  better  results  are  obtained,  and  where 
hmbs  have  been  cut  off  for  sarcoma  of  the  tibia,  fibula,  radius, 
or  ulna,  life  has  been  prolonged  for  several  years,  even  in 
young  individuals. 

Central  tumours  of  bone  are  much  more  favourable  than 
the  periosteal,  and  this  holds  good  when  allowance  is  made 
for  the  fact  that  myeloid  sarcomata  have  been  included  in  the 
statistical  lists  from  which  the  conclusions  were  drawn.  Mye- 
loid sarcomata  give  the  best  results,  and  references  have 
already  been  made  (p.  118)  to  cases  that  have  been  reported. 

The  results  of  ovariotomy  for  sarcoma  are  not  very  en- 
couraging. Thornton*  published  records  of  ten  cases  in  which 
the  patients  submitted  to  operation.  Of  these,  three  died  from 
the  effects  of  the  operation  ;  of  the  seven  which  recovered,  one 
remained  in  good  health  and  had  a  child  two  years  later. 
One  died  a  few  months  after  the  operation  from  recurrence  in 
the  pelvis.  Another  had  recurrence  eighteen  months  later. 
The  remaining  four  died  within  a  year  of  the  operation  from 
dissemination  of  the  growth.  A  careful  analysis  of  the  statis- 
tical tables  of  other  surgeons  skives  almost  identical  results. 
-The  above  facts  indicate  the  greater  risk  of  ovariotomy  for 
sarcoma  than  other  ofenera  of  ovarian  tumours.     This  is  even 

*  Med.  Times  and  Gaz.,  1883,  vol.  i.,  383. 


SARCOMATA. 


123 


more  forcibly  illustrated  by  the  following  facts.  A  search 
through  periodical  literature  enabled  me  to  collect  seventy 
cases  in  which  ovariotomy  had  been  performed  in  girls  under 
fifteen  years  of  age,  with  the  following  results  : — 

Dermoids,   29,  with  25  recoveries. 
Cysts,  29,     „     27 

Sarcomata,  12,     „       5         „ 

The  cases  of  sarcomata  are  subjoined  in  tabular  form. 

OPERATIONS   FOR   OVARIAlsr   SARCOMATA   IN   CHILDREN. 


Reporter. 

Age. 

Result. 

Chenoweth 

8   yrs. 

D. 

Cameron  . 

U   „ 

D. 

Malins 

9      „ 

D. 

Wag-ner  . 

10      „ 

R. 

Croom 

11      „ 

R. 

Wagner  . 

13      „ 

D. 

Smith 

14      „ 

D. 

Tsander  . 

15      „ 

R. 

Thornton 

15      „ 

D. 

Von  Szabo 

15      „ 

D. 

Kelly       .  ■ 

1^      „ 

R. 

Croom 

7     „ 

R. 

Reference. 


Am.  Journal  of  Obdct.,  Vol.  xv.  625. 

Glasgoiv  Med.  Journal,  1SS9.  p.  37. 

Lancet,  1890,  Vol.  i.  1174. 

Arch,  fur  Klin.  Chir.,  Bd.  xxx.  504. 

Obstet.  Trans.,  Hd.,  Vol.  xiv.  93. 

Arch,  fur  Klin.  Chir.,  Bd.  xxx.  504. 

Lancet,  1874,  Vol.  ii.  501. 

Vrach,  No.  48,  1890,  1087. 

Med.  Times  and  Gaz.,  1883,  Vol.  i. ,  p.  "211, 

Arch,  fur  Gyn.,  Bd.  xxxii.  193. 

Keating's  Cyclo23cedia,  Vol.  iii.  739. 

Sd.  Med.  <b  Simj.  Jour.,  1893,  689. 


It  would  have  been  very  interesting  to  knoAv  the  subse- 
quent history  of  the  few  patients  who  recovered,  in  order  to 
make  the  table  as  complete  as  that  which  relates  to  nephrec- 
tomy for  renal  sarcomata  in  young  children.  This  may, 
perhaps,  be  possible  in  future  records. 

It  is  a  fact  that  should  be  emphasised  that  convalescence 
is  very  tardy  after  ovariotomy  for  sarcoma. 

An  examination  of  the  clinical  records  of  ovarian  tumours 
in  children  under  fifteen  brings  out  another  point :  cysts  and 
dermoids,  as  well  as  sarcomata,  compass  the  death  of  the 
patient  at  periods  varying  from  a  few  months  to  three  years, 
when  the  tumours  are  allowed  to  remain. 

It  might  seem,  that  in  the  case  of  the  ovary  the  rapidly 
fatal  results  could  be  ascribed  to  the  fact  that  the  diseased 
gland,  lying  concealed  within  the  pelvis,  had  wrought  serious 
general  mischief  before  the  existence  of  the  tumour  was  dis- 
covered.   This  opinion  is  set  aside  by  the  fact  that  sarcomata  of 


124  CONNECTIVE    TISSUE    TUMOURS. 

the  testis  give  scarcely  better  results,  and  hero  the  glands  are 
more  accessible  to  clinical  observation.  Of  course  the  number 
of  deaths  directly  due  to  the  effects  of  castration  as  compared 
with  ovariotomy  is  very  much  smaller,  indeed  death  from 
castration  is  an  excessively  rare  event. 

When  a  sarcoma  has  been  removed  and  recurs,  this  may  be 
taken  as  an  indication  that  the  morbid  tissue  was  not  com- 
pletely removed,  and  in  the  present  state  of  surgical  art  we 
have  no  absolute  test  whereby  to  decide  this  all-important 
question.  In  a  few  cases,  when  operations  are  in  progress, 
we  find,  to  our  disappointment,  that  conijDlete  eradication  is 
impossible. 

When  a  sarcoma  recurs,  the  surgeon  may,  in  suitable  cases, 
remove  the  recurrent  tumour,  so  long  as  there  is  no  definite 
sign  of  general  infection.  An  encouraging  case  in  this  direc- 
tion has  been  recorded  by  Lawson.*  In  1865  Sir  William 
Fergusson  removed  a  large  parotid  chondro-sarcoma  from  a 
woman ;  from  that  date  to  1883  this  tumour  recurred  and  was 
removed  four  times  by  Fergusson  and  six  times  by  Lawson. 

The  most  important  collection  of  facts  demonstrating  the 
value  of  early  removal  of  sarcomata  is  the  careful  inquiry  into 
retinal  sarcoma  conducted  by  Lawford  and  Collins,  to  which 
reference  has  already  been  made ;  they  bring  out  very  clearly 
the  following  points: — The  quicker  an  eye  is  removed  after  the 
discovery  of  the  disease  the  better  the  prospect  of  cure.  In  the 
majority  of  cases  the  disease  returns  in  the  orbit,  and  in  a  very 
small  proportion  of  cases  secondary  deposits  occur  in  other 
parts.  When  recurrence  takes  place  it  is  rarely  delayed  beyond 
nine  months ;  but  one  undoubted  case  has  been  reported  in 
which  the  disease  returned  three  years  after  the  primary 
operation.  If  three  years  elapse  and  there  is  no  recurrence 
the  recovery  may  be  regarded  as  permanent.  Out  of  fifty-four 
cases  in  Lawford  and  Collins's  list,  eight  patients  were  alive  and 
free  from  recurrence  three  years  after  the  removal  of  the  eye 
for  retinal  glioma;  this,  in  comparison  with  the  inquiries  of 
others,  would  seem  to  indicate  the  proportion  of  recoveries.  It 
is  significant  to  note  that  in  seven  of  these  cases  the  disease 
affected  one  eye  only.  This  shows  the  almost  hopeless  con- 
dition of  the  patient  when  both  eyes  are  affected. 

*  Trans.  Path.  Soc,  vol.  xxxiv.  261. 


SARCOMATA.  125 

The  results  of  operations  for  sarcomata  are  largely  influenced 
according  to  the  species  with  which  we  have  to  deal.  For  in- 
stance, lyinpho-sarcoma  and  the  small  round-celled  species  are 
very  deadly ;  they  recur  quickly,  and  disseminate  rapidly  and 
extensively.  The  presence  of  cartilage  is  a  favourable  sign,  for 
pure  spindle-celled  sarcomata  destroy  life  more  rapidly  than, 
those  that  undergo  chondrification ;  the  more  abundant  the 
cartilage,  the  longer  are  recurrence  and  dissemination  delayed ; 
to  this  there  are  occasional  exceptions.  A  broad  survey  of  the 
clinical  effects  of  the  various  species  and  varieties  of  sarcomata 
permits  their  malignancy  to  be  relatively  expressed  thus  : — 

Lympho- sarcoma. 

Sniall  round-celled  sarcoma. 

Melano-sarcoma. 

Spindle-celled  myo-sarcoma. 

„  chondro-sarcoma. 

Myeloid  sarcoma.* 

An  impartial  consideration  of  the  evidence  at  our  disposal 
clearly  indicates  that  in  a  small  proportion  of  cases  early  re- 
moval of  a  sarcoma  will  effect  a  cure.  In  a  large  proportion 
of  cases  it  retards  the  dissemination  of  the  tumour,  and  there- 
fore prolongs  life.  In  many  instances  it  exercises  no  beneficial 
effect  whatever,  and  a  certain  proportion  of  patients  succumb 
from  the  effects  of  the  operation.  It  is,  however,  imjDortant  to 
keep  well  in  mind  the  fact  that  an  operation,  even  if  it  does 
not  cure  or  even  if  it  retards  the  progress  of  the  disease,  very 
often  relieves  the  patient  not  merely  of  an  encumbrance,  but 
of  a  condition  which  is  the  source  of  great  distress,  mental 
anguish,  and  ofttimes  intense  pain. 

*  Apart  from  the  cases  referred  to  on  page  118,  reference  must  Le  made  to 
Mott's  celebrated  case.  In  1827  he  excised  the  inner  two-thirds  of  the  clavicle 
for  osteo-sarcoma  (myeloid  sarcoma)  of  the  sternal  end  in  a  lad  19  years  old. 
The  patient  survived  the  operation  54  years.  See  Dr.  Porcher,  Am.  Jour.  Med. 
ScL,  vol.  Ixxxv.,  146. 


126 

CHAPTER    XV. 

MYOMATA. 

Myomata  are  tumours  composed  of  luistriped  muscle  fibres. 
This  genus  contains  but  one  species,  sometimes  spoken  of  as 
leiomyomata,  in  contradistinction  to  rliabdomyomata,  tumours 
containing  spindle  cells  possessing  a  transverse  striation.  The 
rhabdomyoma  is  a  variety  of  the  spindle-celled  sarcoma.  {See 
Myo-sarcoma.) 

Myomata  are  met  with  in  the  uterus,  broad  ligament,  ovary, 
ovarian  ligament,  the  round  ligament  of  the  uterus,  the  vagina, 
oesophagus,  stomach,  intestine,  scrotum,  skin,  bladder,  and 
prostate. 

Myomata  are  encapsuled  tumours  composed  of  long  fusi- 
form cells  with  a  rod-like  nucleus ;  the  size  of  the  cells  varies 
greatly  in  different  tumours.  The  bundles  of  muscle  fibres 
are  often  interwoven  in  such  a  manner  that  the  cut  surface 
presents  a  characteristic  whorled  appearance.  Sometimes  it  is 
exceedingly  difficult  to  decide  between  muscle  cells  and  the 
large^  spindle  cells  belonging  to  a  sarcoma,  or  the  cells  of  a 
fibroma. 

Uterine  Myomata. — Before  considering  the  characters  of 
myomata  of  the  uterus  and  the  structures  connected  with  it, 
attention  will  be  drawn  to  a  few  points  in  the  distribution 
of  its  inuscle  fibres. 

The  uterus  is  a  muscular  organ,  and  its  fundus,  with  the 
chief  portion  of  its  body,  is  closely  invested  with  peritoneum 
directly  continuous  laterally  with  the  folds  known  as  the 
broad  ligaments.  The  cavity  of  the  uterus  is  lined  with 
mucous  membrane  rich  in  glands  and  pervaded  with  unstriped 
muscle  tissue.  The  mucous  membrane  is  so  directly  con- 
tinuous Avith  the  muscular  walls  of  the  uterus  that  it  is 
impossible  to  decide  accurately  where  the  mucous  membrane 
ends.  Making  every  allowance  for  this,  the  uterine  mucous 
membrane  contains  a  fair  quantity  of  unstriped  muscle  tissue. 
So  with  the  serous  investment  of  the  uterus;  the  peri- 
toneum forming  the  broad  ligament  contains  a  stratum  of 
unstriped  muscle  tissue,  which  is  directly  continuous  with  the 


MYOMATA.  127 

muscle  tissue  underlying  the  peritoneum  covering  the  uterus. 
Indeed,  the  most  superficial  layer  of  muscle  tissue  on  the 
uterus  belongs  not  to  this  organ  but  to  the  peritoneum.  In 
young  adults  it  is  possible  to  separate  from  the  frmdus  of  the 
uterus,  a  layer  of  tissue  directly  continuous  with  the  muscular 
stratum  of  the  broad  lio-ament. 

Thus  we  have  three  situations  in  the  uterus  in  which 
myomata  may  arise  : — 

1.  In  the  true  uterine  tissue ';  such  are  called  intramural. 

2.  In   the  muscle  tissue  of  the  mucous  membrane,  sub- 

mucous myomata. 

3.  In  the  muscle  tissue  immediately  beneath  the  serous 

membrane  ;  these  are  known  as  subserous  onyomata. 

This  division  is  not  only  pathologically  correct,  but  it  is 
clinically  convenient.  In  addition  to  myomata  falling  under 
each  of  these  heads  it  will  be  necessary  to  consider  similar 
tumours  springing  from  the  muscle  tissue  of  the  (a)  broad 
ligament,  (b)  the  round  ligamient,  and  (c)  the  ovarian 
ligament.  The  last  two  may  be  considered  as  muscular  pro- 
cesses of  the  uterus. 

1.  Intramural  Myomata. — Tumours  originating  in  the 
uterine  Avails  may  be  single  or  nudtiple.  In  their  early  stages 
they  resemble  in  section  knots  in  a  piece  of  wood.  (Fig.  69.) 
These  tumours  are  distinctly  encapsulecl,  and  are  firm  and 
even  hard  to  the  touch. 

In  such  an  early  stage  as  is  represented  in  Fig.  69 
myomata  cause  inconvenience,  and  even  such  small  tumours 
are  accompanied  by  a  slight  enlargement  of  the  uterus.  They 
may  arise  in  any  part  of  the  uterine  wall,  and  there  is  no 
limit  to  their  growth. 

It  not  infrequently  happens  that  when  a  myoma  is  confined 
to  one  wall  of  the  uterus  and  appears  as  a  single  tumour 
externally,  it  will  be  found  on  section  to  consist  of  two  or 
more  tumours  growing  in  association,  but  each  possessing  its 
own  capsule.  This  also  holds  good  of  many  specimens 
described  as  "  general  myomatous  enlargement  of  the  uterus," 
in  which  this  organ  is  so  uniformly  enlarged  as  to  resemble 
an  enormous  pear. 

Uterine  myomata  sometimes  attain  gigantic  proportions, 
weighing  fifty,  sixty,  and  seventy  pounds. 


128  CONNECTIVE    TISSUE    TUMOURS. 

M3^omata  vary  greatly  in  their  rate  of  growth ;  those 
which  grow  slowly  are,  as  a  rule,  very  hard,  and  contain  a 
large  proportion  of  fibrous  tissue ;  such  are  moderately 
vascular.      The    softer   examples   contain   but   little   fibrous 


V 
Fig.  69. — Section  of  a  uterus  showing  a  small  myoma. 

tissue,  their  cells  are  large,  they  grow  rapidly  and  are  very 
vascular.  The  vessels  that  traverse  these  tumours  are  often 
of  large  size,  especially  the  veins,  and  furnish  a  loud  systolic 
bruit  on  auscultation. 

Some  of  these  intramural  myomata  are  so  richly  furnished 
with  blood-vessels  that  on  transverse  section  they  look  not 
unlike  erectile  tumours.  Indeed,  Yirchow*  speaks  of  them  as 
cavernous  or  telangiectatic  myomata.  The  vessels  seen  on 
the  cut  surface  are  for  the  most  part  veins.  An  excellent 
notion  of  the  extreme  vascularity  of  such  tumours  may  be 
gathered  from  Fig.  70,  and  it  may  easily  be  conceived  that, 
under  varying  conditions  of  the  circulation,  such  tumours 
would  alter  in  size,  and  in  some  cases  this  has  been  so  marked 
that  the  tumour  seemed  to  be  erectile. 

The  amount  of  blood  myomata  contain  is  well  seen  when 

*  "Die  Krankhaften  Geschwiilste,"  bd.  iii.,  195. 


MYOMATA. 


129 


operating  upon  them.  When  blood  is  prevented  from  entering 
them  the  cut  surface  is  quite  white,  and  when  it  is  allowed 
to  enter,  the  tumour  swells  up  like  a  sponge  and  at  once 
becomes  of  a  lively  pink  colour. 


0. — Veiy  A asoulii  uteime  niyoini  seen  111  section      {■Lftei  I  i    ho     ) 


2,  Submucous  Myomata. — Myomata  springing  from  the 
nmscle  tissue  in  the  mucous  membrane,  as  soon  as  they  attain 
an  appreciable  size,  project  into  the  uterine  cavity  and  give 
rise  to  one  variety  of  "  fleshy  polypus  of  the  womb."  Sub- 
mucous myomata  are  at  first  sessile  and  invested  on  the 
surface  which  projects  into  the  cavity  of  the  uterus  with 
mucous  membrane.  As  they  increase  in  size  they  dilate  the 
uterine  cavity  and  tend  to  become  pedunculated. 

The  presence  of  the  tumour  within  the  uterus  acts  in^^the 

same  way  as  an  impregnated  ovum,  inasmuch  as  its  continued 

increase   in   size   reacts   upon   the  uterine   tissue  and   leads 

to  great  thickening  of  its  walls,  accompanied  by  increased 

J 


130 


CONNECTIVE    TISSUE   TUMOUIiS. 


vascularity,  which  is  often  inanifested  by  irregular  ha^iriorrliage 
from  the  uterus,  or  at  least  by  undue  losses  of  blood  at  the 
menstrual  periods. 

It  occasionally  happens  that  the  pedicle  of  a  submucous 
myoma  may  become  so  elongated  as  to  allow  the  myoma  to 
pass  through  the  cervical  canal  and  emerge  into  the  vagina, 
and  even  protrude  at  the  genital  orifice.  When  this  happens, 
an  interesting  change  takes  place  in  the  character  of  the 
epithelium  of  the  extruded  part.  So  long  as  the  myoma  is 
contained  within  the  cavity  of  the  uterus,  the  mucous  mem- 
brane covering  it  is  indistinguishable  from   that  lining  the 


Fig.  71. — Mieroscopieal  appearance  of  the  mucous  membrane  covering  a  prolapsed  uterine 
myoma,  showing  mutation  of  columnar  ciliated  into  stratified  epithelium  as  a  result  of 
pressure.    (After  (Jervais.) 

general  cavity  of  the  uterus,  and  the  surface  epithelium,  as 
well  as  that  lining  the  recesses  of  the  glands,  is  of  the  columnar 
ciliated  variety.  When  the  myoma  enters  the  vagina,  the 
epithelium  covering  the  projecting  portion  becomes  converted 
into  stratified  epithelium  on  all  those  parts  submitted  to 
pressure,  but  the  epithelium  in  the  glandular  recesses  not 
exposed  to  pressure  remains  columnar  and  ciliated.  This 
mutation  of  epithelium  is  shown  in  Fig.  71. 


MYOMATA.  131 

The  extrusion  of  a  myoma  through  the  cervical  outlet  of 
the  uterus  sometimes  ends  in  complete  detachment  of  the 
tumour.  This  is,  of  course,  curative,  but  it  is  very  rare ;  un- 
fortunately the  extrusion  more  frequently  leads  to  secondary 
changes,  which  are  in  the  long  run  inimical  to  life.  When 
a  large  myoma  passes  beyond  the  external  orifice  of  the 
uterus,  the  part  lying  within  the  canal  is  firmly  grasped  by 
the  contraction  of  the  uterine  walls  bounding  the  internal 
orifice.  Should  the  tumour  be  very  vascular  the  venous  circu- 
lation is  interfered  with,  and  the  projecting  part  becomes 
cedematous.  The  sequence  in  such  a  case  is  identical  with  oedema 
of  a  leg  secondary  to  thrombosis  of  the  corresponding  external 
iliac  vein.  Should  the  compression  continue,  the  extruded 
parts  become  congested  and  may  even  necrose,  and  as  the  dead 
tissue  is  in  a  situation  easily  accessible  to  air,  and  consequently 
to  putrefactive  organisms,  gangrene,  Avith  all  its  attendant 
evils,  is  the  result. 

Myomata,  sometimes  of  large  size,  arise  from  the  neck  of 
the  uterus  and  project  into  the  vagina,  and  thus  simulate  very 
closely  the  large  pedunculated  tumours  which  grow  from  the 
uterine  fundus. 

A  submucous  myoma  may  invert  the  fundus,  and  an 
inverted  uterine  fundus  sometimes  simulates  a  submucous 
myoma. 

3.  Subserous  Myomata. — Tumours  growing  from  the 
layer  of  muscle  tissue  immediately  subjacent  to  the  peritoneal 
covering  of  the  uterus,  when  numerous,  rarely  attain  a  large 
.size.  When  the  number  is  limited  to  three  or  four,  one  or 
more  of  them  may  attain  moderate  proportions.  Like  the  sub- 
mucous variety,  subserous  myomata  quickly  become  peduncu- 
lated, and  when  numerous  they  cause  the  uterus  to  assume 
a  characteristic  tuberous  appearance.  Sometimes  as  many  as 
fifteen  or  twenty  of  these  protuberances  may  be  counted  on  a 
uterus,  and  they  vary  in  size  from  a  pea  to  a  large  walnut.  In 
.such  cases,  even  when  no  intramural  myomata  are  present, 
the  walls  of  the  uterus  are  thicker  than  natural.  Subserous 
myomata  of  this  character  rarely  cause  any  inconvenience, 
and  are  often  found  after  death  in  individuals  in  whom  they 
have  never  produced  the  least  inconvenience  during  life,  or 
in  whom  their  presence  has  not  even  been  suspected.     Large 


132 


CONNECTIVE    TISSUE    TUMOURS. 


single,  pedunculated,  subserous  myoinata,  weighing  two  or 
more  pounds,  sometimes  cause  trouble  from  tlie  mechanical 
effects  they  are  liable  to  produce. 

Any  of  the  three  varieties  may  occur  together  in  the  uterus 
■ — indeed  it  is  usual  to  find  the  subserous  and  intramural 
myomata  associated.    (Fig.  72.)    Intramural  tumours  are  often 


Fig.  72. — Section  of  a  uterus  with  multiple  myomata. 

present  alone;  but  it  is  by  no  means  rare  to  find  moderately 
large  examples  in  the  uterine  walls  accompanied  by  a  small  sub- 
mucous myoma,  and  the  latter  is  far  more  frequently  the  source 
of  dangerous  haemorrhage  and  pain  than  its  large  companions. 
It  is  usual,  in  works  dealing  with  uterine  myomata,  to  de- 
scribe each  variety  as  having  a  common  origin  in  the  uterine 
wall  and  then  remaining  intramural,  or  becoming  subserous,  or 
submucous,  according  to  circumstances.  It  cannot  be  denied 
that  occasionally  large  intramural  myomata  will  project  into 
the  uterine  cavity  and  even  become  extruded,  but  such  rarely 
become  pedunculated ;  they  will  also  often  protrude  on  the 


MYOMATA.  133 

iibdominal  asjject  of  the  uterus,  but  a  critical  dissection  will 
show  that  there  is  a  layer  of  uterine  tissue  intervening  betAveen 
the  tumour  and  the  peritoneum.  The  majority  of  small 
subserous  myomata  spring  up  in  the  subperitoneal  stratum  of 
muscle  tissue  and  belong  to  it.  In  the  same  'way  the  small  sub- 
mucous myomata  originate  in  the  muscle  tissue  of  the  uterine 
mucous  membrane. 

Uterine  myomata  are  liable  to  secondary  changes,  which  it 
will  now  be  convenient  to  consider. 

Mucoid  Degeneration. — Large  uterine  myomata  are  es- 
pecially prone  to  undergo  this  change,  whereby  large  tracts  of 
the  tumoiu'  substance  soften  and  become  converted  into  mucin; 
in  some  specimens  this  takes  place  so  extensively  that  the 
tumour  is  converted  into  a  spurious  cyst,  the  only  part  which 
retains  its  original  structure  being  the  capsule.  Myomata  of 
this  description  are  often  described  as  "  hbro-cystic  tumours." 
The  actual  conversion  of  the  tissue  substance  is  preceded  by 
cedema  of  the  connective  tissue,  and  the  cells  assume  the 
characteristic  spider-like  form  to  which  the  term  myxoma  is 
applied.  Sections  of  the  tissue  which  forms  the  boundary  of 
the  softened  spaces  in  the  tumour  exhibit  every  gradation,  from 
fusiform  cells  to  the  irregularly  branched  cells  peculiar  to 
myxomatous  tissue,  embedded  in  a  structureless  matrix  identi- 
cal in  its  physical  characters  with  the  vitreous  humour  of  the 
eye.  Mucoid  changes  in  uterine  myomata  are  usually  accom- 
panied by  rapid  increase  in  the  size  of  the  tumour. 

Fatty  Metaniorphosis.  —  Uterine  myomata  sometimes 
undergo  this  change.  In  rare  instances  a  localised  collection  of 
fat  has  been  found  in  the  middle  of  a  pedunculated  myoma. 

Calcification. — Old  uterine  myomata,  both  large  and  small, 
are  liable  to  become  inliltrated  with  earthy  matter.  The 
change  only  occurs  in  slow-growing  tumours  containing  a 
large  proportion  of  fibrous  tissue.  The  calcareous  material  is 
not  deposited  in  an  irregular  manner  in  the  tissues  of  the 
tumour,  but  corresponds  to  the  disposition  of  the  fibres  ;  on 
examining  the  sawn  surface  of  a  completely  calcified  uterine 
myoma  we  find  the  whorled  disposition  of  the  fibres  so  com-' 
pletely  reproduced  as  to  leave  no  doubt  as  to  the  nature  of  the 
mass.  When  these  calcified  tumours  are  macerated,  and  the 
decayed  tissues  washed  away,  the  earthy  matter  retains  the 


184  _         CONNECTIVE    TISSUE   TUMOUTiS. 

shape  of  the  tumour,  but  its  exterior  presents  an  irregular, 
porous,  almost  worm-eaten  appearance.  The  calcitication  is 
confined  to  the  tumour  itself,  and  though  we  may  occasionally 
find  isolated  nodules  of  earthy  matter  dotted  about  the  capsule, 
this  part  of  the  tumour  is  not  converted  into  a  hard,  resisting 
shell. 

If  a  partially  calcified  myoma  became  extruded  into  the 
vagina  and  decomposed,  the  soft  tissues  escaping  with  the 
discharges,  it  can  easily  be  understood  that  the  residual  cal- 
careous mass,  in  days  when  the  anatomy  of  such  tumours  was 
not  known,  would  be  somewhat  of  a  clinical  puzzle.  It  was 
formerly  believed  that  these  calcareous  masses  were  formed  in 
the  uterus,  and  they  were  termed  uterine  calculi. 

There  is  an  admirable  specimen  preserved  in  the  museum 
of  the  Middlesex  Hospital ;  it  was  described  by  James  M. 
Arnott*  in  1840,  and  the  history  of  the  patient  is  somewhat 
remarkable.  A  maiden  lady  of  seventy-two  years  was  knocked 
down  by  a  large  dog  and  fell  forwards  on  the  pavement.  She 
was  seized  with  severe  pain  in  the  belly,  and  died  in  thirty- 
four  hours.  At  the  autopsy  a  circular  orifice  was  found  in  a 
coil  of  ileum  which  lay  between  the  anterior  abdominal 
Avail  and  a  calcified  tumour  of  the  uterus.  There  was- 
extravasation  of  fseces  and  intense  peritonitis.  The  tumour, 
which  was  as  large  as  a  child's  head,  apparently  originated  in 
the  anterior  wall  of  the  uterus.  Several  small  tumours,  also 
calcified,  were  attached  by  pedicles  to  its  capsule. 

Arnott's  account  of  the  specimen  is  rendered  more  valuable 
by  an  account  of  the  chemical  composition  of  the  mass 
furnished  by  Professor  Daniell.  It  contained  56  per  cent,  of 
phosphate  of  lime,  with  a  small  quantity  of  phosphate  of 
magnesia,  35  parts  of  animal  matter,  5  parts  of  carbonate  of 
lime,  and  4  of  alkaline  sulphates,  phosphates,  and  chlorides. 

Similar  masses  are  now  and  then  found  in  old  graves,  and 
are  sometimes  imagined  to  be  very  large  urinary  calculi. 

Subserous  myomata  are  very  prone  to  calcify,  and  their 
stalks  being  thin  are  apt  to  break  and  allow  the  calcified 
nodules  to  tumble  into  the  general  peritoneal  cavity.  These 
nodules  often  find  their  way  into  all  sorts  of  queer  recesses, 
and  sometimes  find  lodgment  in  hernial  sacs. 

^'  Medico-Chir.  Trans,   vol.  xxiii.,  p.  199. 


MYOMATA.  135 

t^eptic  Infection. — It  occasionally  happens  that  a  myoma 
which  has  existed  for  many  years  and  given  rise  to  little  or  no 
inconvenience  suddenly  begins  to  enlarge  rapidly  and  assumes 
formidable  proportions.  This  change  is  often  accompanied 
by  high  temperature,  rapid  pulse,  and  other  signs  indicative 
of  septicaemia,  and  almost  invariably  ends  fatally  unless  the 
nature  of  the  case  is  promptly  recognised  and  the  tumour 
removed.  These  changes  are  analogous  to  those  which  occur 
in  a  myoma  when  it  protrudes  into  the  vagina  and  ulcerates, 
the  infection  ending  in  gangrene. 

As  far  as  my  observations  have  extended,  septic  infection 
of  a  uterine  myoma,  excluding  the  pedunculated  variety,  has 
followed  injury  inflicted  by  a  uterine  sound ;  changes  in  the 
pedicle  following  oophorectomy  performed  for  the  purpose  of 
anticipating  the  menopause  ;  and  osmosis  of  fluid  and  gas 
from  an  adherent  piece  of  gut,  or  a  hollow  viscus  like  the 
bladder. 

The  appearance  of  an  infected  myoma  is  very  striking. 
On  section  it  looks  oedematous  and  sometimes  exhales  a  sickly 
odour.  Microscopically  the  muscle  cells  are  separated  by 
multitudes  of  inflammatory  cells,  many  of  which  seem  to 
aggregate  in  colonies,  and  by  appropriate  methods  micro- 
organisms may  be  demonstrated. 

The  occurrence  of  septic  changes  in  a  myoma  of  the  uterus, 
and  the  consequent  infiltration  of  the  tissue  of  the  tumour  by 
leucocytes  and  inflammatory  cells,  causes  sections  prepared 
from  it  to  resemble  those  obtained  from  a  sarcoma,  and  there 
can  be  little  doubt  that  in  many  specimens  that  have  been 
described  as  "  sarcomatous  degeneration  of  a  uterine  fibroid," 
the  change  and  appearance  and  rapid  growth  of  the  tumour 
were  the  result  of  septic  changes. 

There  are  a  few  cases  recorded  by  reliable  observers  in 
which  a  myoma  has  existed  in  the  walls  of  the  uterus  for 
several  years,  and  then,  without  obvious  reason,  the  tumour 
has  increased  rapidly  in  size,  become  painful,  and  disseminated. 

In  1883  Dr.  Finlay*  published  a  careful  account  of  the 
case  of  a  woman  fifty-nine  years  old,  who  had  for  fifteen  years 
noticed  a  hard  swelling  in  the  lower  part  of  her  belly ;  it  had 

*  Trans.  Path.  Soc,  vol.  xxxiv,,  p.  177.  [See  also  Doran,  ibid.,  vol.  xli., 
p.  206.) 


136  CONNECTIVE    TISSUE    TUMOURS. 

not  caused  her  any  inconvenience  until  shortly  before  she 
came  under  Dr.  Finlay's  observation.  She  sought  advice 
because  the  tumour  had  increased,  in  size  and  become  painful. 
Peritonitis  supervened  and  she  died.  I  made  the  post-mortem 
examination  and  found  a  pedunculated  myoma  as  large  as  a 
child's  head  (15  by  11  cm.)  attached  to  the  fundus  of  the 
uterus ;  it  was  adherent  to  and  had  penetrated  the  bladder 
and  intestine.  Secondary  growths  were  found  at  the  base  of 
the  right  lung,  on  the  wall  of  the  left  ventricle  of  the  heart, 
and  in  the  left  kidney.  The  microscopical  features  of  the 
tumour  were  characteristic  of  a  myoma  and  spindle-celled 
sarcoma ;  the  secondary  nodules  were  identical  in  structure 
with  the  large  tumour. 

Clinical  Features. — The  occurrence  of  uterine  mj^omata 
before  pubert}^  is  unknown ;  these  tumours  are  rarely 
recognised  clinically  before  the  age  of  twenty-five ;  from  this 
age  they  increase  in  frequency,  which  attains  the  maximum 
between  the  thirty-fifth  and  forty-fifth  years.  Myomata  of 
the  uterus  are  more  common  in  old  maids  than  in  married 
women.  This  statement  is  often  disputed  by  gynaecologists 
who  do  not  frequent  the  deadhouse.  Very  many  examples 
of  myomata  are  found  post  mortem  whose  presence  was  not 
even  suspected  during  life.  Of  these  the  purely  clinical 
gynsecologist  takes  no  cognizance.  The  troubles  produced  by 
myomata  of  the  uterus  during  life  vary  greatly.  As  has 
already  been  mentioned,  many  women  live  years  without 
being  aware  that  they  have  a  tumour.  In  others  the  tumour 
grows  slowly  and  gives  no  indication  of  its  presence  until  it  is 
large  enough  to  become  impacted,  then  troubles  arise  in  con- 
nection with  the  bladder,  ureters,  or  rectum ;  or  the  tumour 
is  so  large  as  to  rise  above  the  brim  of  the  pelvis  and  produce 
an  obvious  enlargement  of  the  belly.  Many  myomata  give 
few  signs  of  their  presence  until  they  protrude  through  the 
cervix,  and  in  a  fair  proportion  of  cases  frequent  discharges 
of  blood  from  the  uterus  is  an  important  sign.  Women  will 
sometimes  state  that  the  tumour  becomes  obviously  enlarged 
immediately  before  a  menstrual  period  and  diminishes  as  the 
flow  ceases. 

I'YYipaction. — An   important    clinical   feature    of    uterine 
myomata  is  their  tendency  to  become  impacted  in  the  pelvis 


MYOMATA.  137 

and  exercise  baneful  pressure  upon  the  organs  contained 
therein. 

A  uterine  myoma  is  said  to  be  impacted  when  it  tits  the 
true  pelvis  so  tightly  that  the  tumour  cannot  rise  upwards 
into  the  belly.  In  many  cases  the  tumour  is  so  firmly  held 
in  the  pelvis  that  it  cannot  be  pushed  upwards  except  with 
the  exercise  of  considerable  force,  and  even  this,  in  some  cases, 
is  ineffectual  in  dislodging  it. 

Impaction  arises  from  several  causes,  some  of  which  will 
be  described.  It  has  already  been  pointed  out  that  uterine 
myomata,  especially  those  which  involve  the  walls  of  the 
uterus  uniformly,  are  very  vascular ;  this  vascularity  is  most 
marked  when  they  occur  in  women  between  thirty-five  and 
forty-five  years  of  age.  In  such  cases  uterine  myomata, 
immediately  before  the  onset  of  a  menstrual  period,  enlarge, 
and  in  some  examples  the  increase  in  size  is  very  obvious. 
When  the  myoma -is  of  such  a  size  that  during  an  inter-men- 
strual period  it  is  easily  accommodated  in  the  true  pelvis,  and 
perhaps  the  crown  of  the  cyst  is  perceptible  to  the  hand  when 
pressed  upon  the  hypogastric  region,  it  will  move  freely  in 
the  pelvis  without  exerting  dangerous  or  even  inconvenient 
pressure.  At  the  onset  of  a  menstrual  period  such  a  tumour 
will  become  turgescent  and  compress  the  urethra  against  the 
pubic  symphysis,  and  cause  complete  retention  of  urine,  neces- 
sitating for  a  few  days  the  use  of  the  catheter.  As  the 
menstrual  period  declines,  the  urethra  is  set  free.  In  such  a 
case  the  impaction  is  only  temporary,  but  it  recurs  with  each 
period,  and  eventually  establishes  dilatation  of  the  ureters  and 
pelves  of  the  kidneys  (hydronephrosis).  In  some  cases  of 
im|)action  through  menstrual  turgescence  the  urethra  may 
escape,  but  the  ureters  will  be  pressed  upon  at  the  pelvic 
brim. 

A  myomatous  uterus  may  become  impacted  even  when 
the  tumour  it  contains  is  of  moderate  dimensions.  A  myoma 
as  large  as  a  fist  growing  from  the  posterior  uterine  wall  will 
cause  retroversion  of  the  uterus  ;  the  tumour  will  then  lodge 
in  the  hollow  of  the  sacrum  and  dip  into  the  space  between 
the  utero-sacral  ligaments ;  in  this  position  it  exercises 
pressure  upon  the  ureters,  which  leads  to  hydronephrosis  on 
one  or  both  sides. 


138  CONNECTIVE   TTHSUE  TUMOUItH. 

Another  forin  of  impaction  occurs  when  a  nuiiiljer  of 
myomatous  nodules  spring  from  the  uterus  and,  becoming 
wedged  under  the  promontory  of  the  sacrum,  prevent  the 
uterus  as  it  increases  in  size  from  rising  out  of  the  true  pelvis, 

A  myoma  which,  during  the  sexual  period  of  life,  reaches 
"to  the  umbilicus,  or  higher,  will  sometimes  shrink  so  much 
after  the  menopause  that  it  will  retire  into  the  pelvis  and  fit 
that  cavit}^  so  completely  as  to  give  rise  to  symptoms  of 
impaction. 

Injurious  pressure  is  often  exercised  by  uterine  myomata 
apart  from  impaction.  For  instance,  a  large  myoma  sometimes 
occupies  the  false  pelvis,  and  extends  even  as  high  as  the 
ensiform  cartilage.  Such  tumours  will  weigh  many  pounds, 
and,  being  far  too  large  to  enter  the  true  pelvis,  will  rest  upon 
its  brim,  and  by  their  weight  compress  the  iliac  veins  and 
cause  oedema  of  one  or  both  legs,  or  press  upon  the  colon 
and  induce  obstinate  constipation  or  fatal  obstruction,  or 
resting  on  one  or  both  ureters  produce  hydronephrosis. 

The  Rate  of  Growth. — Few  observations  have  been  made 
as  to  the  average  rate  of  increase  of  myomata.  Matthews 
Duncan  in  connection  with  this  matter  writes  : — "  A  uterine 
myoma  is  not  like  an  apple,  attains  a  certain  size,  and  then 
ceases  to  grow.  In  a  life  it  may  grow  no  bigger  than  an 
apple,  or  it  may  reach  the  umbilicus."  He  also  states  that  a 
myoma  of  the  size  of  a  foetal  head  probably  represents  a  year's 
growth.  It  would  attain  the  size  of  a  man's  head  in  three 
years,  and  be  as  large  as  the  uterus  at  the  full  time  of  preg- 
nancy in  twelve  years.  Soft  myomata  grow  quickly,  hard 
tumours  grow  very  slowly ;  some  soft  myomata  disappear 
rapidly  after  the  menopause,  a  few  grow  rapidly  after  this 
event.  Hard  myomata  usually  cease  to  grow  after  that 
change;  a  few  shrink  somewhat,  but  the  majority  remain 
in  statu  quo  and  slowly  calcify. 

Mode  of  Death  from  Uterine  Myomata. — Although  there 
is  no  tumour  so  common  in  women  as  a  uterine  myoma,  there  is 
very  great  difference  of  opinion  as  to  their  influence  on  the  life 
of  the  individual.  Matthews  Duncan  writes  :  "  I  am  sure  the 
fatal  number  of  cases  is  greater  than  is  generally  supposed." 
This  thoughtful  man  further  states :  "  A  woman  with  an 
enormous  fibroid  will  not  live  to  be  an  aged  woman." 


MYOMATA.  139 

The  chief  causes  of  death  are  : — 

Hoi'morrhage. — Copious  bleeding  leads  to  death,  directly  or  in- 
directly, nearly  as  frequently  as  post-partum  htemorrhage 
causes  death  directly.  Often  it  causes  death  indirectly  by 
producing  extreme  anaemia.* 

Mechanical  Effects. — Pressure  on  the  bowels ;  pressure  on 
urethra,  leading  to  retention  of  urine,  cystitis,  and  septic 
nephritis ;  pressure  on  one  or  both  ureters,  hindering  the 
flow  of  urine  and  inducing  hydronephrosis,  etc. 

Pregnancy  in  a  uterus  containing  a  myoma  may  terminate 
happily,  but  more  often  it  leads  to  abortion,  and  seriously 
imperils  the  life  of  the,  mother.  Exceptionally,  when  a 
uterine  myoma  and  pregnancy  co-exist,  the  myoma  dis- 
appears with  the  involution  of  the  uterus. 

Peritonitis. — When  a  pedunculated  myoma  becomes  gan- 
grenous, the  uterine  mucous  membrane  will  sometimes 
necrose,  and  septic  matter  finds  its  way  along  the  Falloj^ian 
tubes  and  fatally  infects  the  peritoneum. 

Myomata  of  the  Broad  Ligament. — It  has  already  been 
mentioned  that  the  connective  tissue  of  the  broad  ligament 
contains  a  quantity  of  plain  muscle  tissue  directly  continuous 
with  that  which  underlies  the  peritoneal  investment  of  the 
uterus.  This  muscle  tissue  is  occasionally  the  source  of  myo- 
mata. In  their  early  stages  broad  ligament  myomata  are  of 
oval  shape,  encapsuled  and,  as  a  rule,  bilateral.  They  do  not 
cause  much  inconvenience  until  they  attain  the  size  of  cocoa- 
nuts  ;  even  then  they  can  be  easily  enucleated  from  between 
the  layers  of  the  ligament.  After  reaching  a  certain  size  they 
sometimes  grow  with  extraordinary  rapidity,  and  in  a  few 
months  attain  a  weight  of  twenty  pounds  or  more.  As  these 
tumours  rise  out  of  the  pelvis  they  carry  the  uterus  and  its 
appendages  with  them,  and  the  relation  of  this  organ  to  the 
tumours  is  indicated  in  Fig.  73.  There  is  little  doubt  that  the 
rapid  increase  in  the  rate  of  growth  in  these  myomata  is  due 
to  septic  infection  in  many  cases,  and  in  two  that  have  come 
under  my  own  observation  I  have  been  able  to  assure  myself 
of  the  fact,  and  traced  the  infection  to  an  adherent  coil  of 
intestine  in  each  instance.     Coincident  with  the  rapid  growth 

*  Matthews  Duncan,  "Clinical  Lectures,"  3rd  ed.,  1886. 


140 


(JONNECTfVE   Tlf^l^UE    TUMOUItS. 


of  the  tumour  the  health  of  the  patient  slitters,  and  the  pres- 
sure it  exerts  upon  the  veins  at  the  brim  of  the  pelvis  leads 
to  oedema  of  the  lower  limbs.     This,  in  conjunction  with  the 


serious  depreciation  of  the  patient's  health,  has  led  a  few 
surgeons  to  regard  these  tumours  as  rapidly-growing  spindle- 
celled  sarcomata. 


MYOMATA.  141 

In  some  cases  the  tuinour  will  raise  the  anterior  layer  of 
the  broad  ligament  and  extend  along  the  subperitoneal  tissue 
so  as  to  lie  between  the  peritoneum  and  the  anterior  abdominal 
wall,  reaching  the  level  of  the  navel. 

The  tumour  most  likely  to  be  confounded  with  a  broad 
ligament  myoma  would  be  a  myoma  growing  from  the  side  of 
the  uterus  and  pushing  its  way  between  the  layers  of  the 
ligament. 

This  description  of  broad  ligament,  or  mesometric  myo- 
mata  is  founded  upon  a  study  of  eleven  cases.  All  occurred 
in  women  over  thirty-tive  years  of  age.  Three  of  the  tumours 
equalled  cocoa-nuts,  one  Avas  as  big  as  an  average  fist,  the 
remainder  were  large  masses  Aveighing  upwards  of  sixteen 
pounds.  These  specimens  contained  calcified  tracts;  the  softer 
parts  were  succulent,  like  the  pulp  of  an  orange,  and  yielded  a 
yellow,  tenacious,  highly  albuminous  fluid;  actual  cavities  Avere 
present  in  some  of  the  specimens,  and  in  three  gangrenous 
patches  existed. 

Myomata  of  the  Round  Ligament  of  the  Uterus. — This 
ligament,  like  the  ovarian  ligament,  is  practically  a  process  of  the 
muscular  tissue  of  the  uterus.  A  part  of  the  round  ligament 
lies  in  the  pelvis  under  cover  of  the  anterior  layer  of  the  broad 
ligament ;  the  terminal  third  traverses  the  inguinal  canal.  Oval 
tumours  composed  of  smooth  muscle-fibre  mixed  with  fibrous 
tissue  have  been  observed  in  connection  with  the  intra-  and 
extra-pelvic  segments  of  this  ligament. 

Matthews  Duncan*  described  a  tumour  of  the  size  and  shape 
of  a  hen's  egg;  it  lay  quite  free  in  front  of  the  right  broad  liga- 
ment ;  the  round  ligament,  which  could  be  traced  to  the  surface 
of  the  tumour,  ended  in  its  capsule.  The  structure  of  the 
tumour  was  that  of  a  dense  fibroid,  with  numerous  cretaceous 
points  near  its  centre. 

Fibro-myomata  of  the  section  of  the  ligament  traversing 
the  inguinal  canal  have  been  several  times  observed ;  they  are 
oval  in  shape,  and  sometimes  reach  the  size  of  cocoa-nuts,  t 

Myomata  of  the  Ovary  and  its  Ligament. — Tumours  of 
the  ovary  composed  of  muscle  fibre  or  a  mixture  of  muscle  and 
fibrous  tissue  are  very  rare.     Ovarian  myomata  may  attain 

*  Trans.  Obstet.  Soc,  Edin.,  vol.  iv.,  195. 

t  Spencer  Wells,  Trans.  Path.  Soc,  vol.  xvli.  188. 


142 


GUN^^ECTIVE    TISSUE   TUMOVRH. 


laro-e  proportions,  and  spechnens  have  been  recorded  weighing 
fifteen  pounds.  These  tumours  in  their  minute  structure 
resemble  uterine  myomata,  but  they  are  not  so  liable  to  the 
secondary  changes  v*diich  affect  similar  tumours  of  the  uterus 
or  broad  ligament. 

Myomata  are  rarer  in  the  ovarian  ligament  than  in  the 
ovary;  usually  they  are  verj^  small;  the  largest  specimen  which 
has  come  under  my  notice  was  no  bigger  than  a  child's  fist.  It 
projected  on  the  posterior  aspect  of  the  broad  ligament,  and 
resembled  an  enlarged  ovary. 

Myomata  of  the  Fallopian  Tube. — A  myoma  of  the 
Fallopian  tube  is  an  excessively  rare  tumour — so  rare,  indeed, 


Myoma. 


Fig.  74. — Myoma  of  the  Falloiiiaii  tube. 


that  my  experience  is  limited  to  one  specimen  :  this  occurred 
in  a  woman  twenty-nine  years  of  age  in  association  with  an 
ovarian  dermoid.     (Fig.  74.) 

The  myoma  in  this  instance  was  of  the  size  and  shape  of  a 
Tangerine  orange ;  it  involved  the  whole  thickness  of  the  tube, 
and  a  narrow  channel  lined  with  mucous  membrane  traversed 


MYOMATA.  .  143 

the  centre  of  the  tumour,  and  a  segment  of  tube,  2  cm.  in 
length,  intervened  between  it  and  the  angle  of  the  uterus. 
To  the  naked  eye  the  tumour  presented  all  the  characters  of 
a  uterine  myoma,  and  under  the  microscope  it  was  found  to 
consist  of  typical  smooth  muscle  cells. 

Myomata  of  the  Alimentary  Canal. — Hilton  Fagge*  met 
with  a  myoma  in  the  oesophagus  in  a  man  thirty-eight  years 
of  age.  It  grew  in  the  anterior  wall  of  the  gullet  just  below 
the  level  of  the  bifurcation  of  the  trachea.  The  tumour  was 
ovoid,  and  measured  5  cm.  in  its  long  and  about  3  cm.  in  its 
short  axis.  The  surface  in  relation  with  the  mucous  coat  was 
smooth  and  rounded,  but  that  in  contact  with  the  muscular 
coat  was  somewhat  nodulated  and  inseparably  adherent  to  the 
longitudinal  muscle  fibres  of  the  oesophagus.  On  section  the 
tumour  had  the  colour  and  general  appearance  of  a  myoma  of 
the  uterus,  and  microscopically  consisted  of  unstriped  muscle- 
libre.     It  caused  no  symptoms  during  life. 

Virchow  f  refers  to  a  specimen  which  he  found  at  the 
cardiac  end  of  the  oesophagus ;  it  was  a  spherical  tumour 
1  cm.  in  diameter,  situated  in  the  submucous  tissue,  but 
was  connected  with  the  muscular  coat  of  the  gullet. 

Yirchow  also  mentions  that  myomata  are  more  frequent 
in  the  stomach  than  in  other  parts  of  the  intestinal  tract,  and 
is  of  opinion  that  gastric  myomata  are  frequently  confounded 
with  cancers,  fibromata,  and  even  with  cysts.  They  may 
assume  the  form  and  size  of  a  cherry,  a  haricot,  or  an  almond, 
but  sometimes  greatly  exceed  these  dimensions.  ■ 

Dr.  Wesener  J  found  a  myoma  as  large  as  a  plum,  growing 
from  the  wall  of  the  duodenum  15  cm.  below  the  pylorus. 
The  patient  was  a  man  hfty-tive  years  of  age.  The  symptoms 
were  those  characteristic  of  malignant  disease  of  the  pylorus — 
viz.,  vomiting,  emaciation,  and  dilatation  of  the  stomach.  No 
tumour  was  perceived  during  life  ;  it  projected  into  the  lumen 
of  the  gut,  and  its  surface  was  slightly  ulcerated. 

Myoma   of  the    Bladder. — Gibbons   and    Parker  §    have 

*  Trans.  Path.  Soc,  vol.  xxvi.,  p.  94. 

t"Die  Krankheiten  Geschwiilste,"  bd.  iii.  126;  and  Kidd,  Trans.  Path. 
Soc,  vol.  XXXV.  196. 

"^  Virchow's  "  Archiv,"  bd.  xciii.  377. 
§  Trans.  Clin.  Soc,  vol.  xxi.  58. 


]44 


CONNECTIVE   TIHHUE  TUMOUR H. 


recorded  the  details  of  a  myoma  which  they  successfully 
removed  from  the  bladder  of  a  girl  eighteen  years  of  age. 
A  good  drawing  accompanies  the  description,  showing  the 
histoloo'ical  features  of  the  tumour. 

Cutaneous  Myomata. — Myomata  arise  in  connection  with 
the  skin.  I  once  removed  from  the  scrotum  of  a  hoy  a  few 
months  old  a  rounded  firm  tumour  with  a  diameter  of  1  cm. 
On  section  it  had  a  yellowish  tint,  and  when  submitted  to  the 
microscope  was  found  to  be  made  up  of  unstriped  muscle  fibre. 

Dr.  Serg.  Marc*  met  with  a  myoma  on  the  occiput  of  a 
female  child  three  weeks  old  (Fig.  75).    The  tumour  was  noticed 


Fig.  75.— Congenital  subcutaneous  myoma  of  the  occiput.     {After  Marc.) 

at  birth.  When  it  came  under  observation  at  the  Prince  Peter 
von  Oldenburg  Hospital,  St.  Petersburg,  it  had  a  diameter  of 
3-5  cm.  at  the  base  ;  the  skin  covering  it  was  slightly  pig- 
mented, and  the  summit  of  the  tumour  was  sparsely 
covered  with  lanusfo-like  hair,  but  around  its  base  the  hair 
was  abundant.  The  tumour  was  firm  to  the  touch,  and 
manipulation  caused  no  pain ;  when  removed  it  was  found  to 
be  encapsuled,  and  on  microscopical  examination  exhibited 
the  characters  of  a  myoma.  The  histological  details  are 
described  with  great  care. 

Treatment. — It  is  by  no  means  an  easy  task  to  frame  rules 
for  the  treatment  of  uterine  myomata.  It  is  quite  certain 
that  if  these  tumonrs  could  be  removed  with  the  same  ease 

*  Virchow's  "  Archiv,"  bd.  cxxv.  543. 


MYOMA  TA.  145 

and  safety  as  ovarian  tumours,  this  would  be  the  proper  course  ; 
but  until  surgeons  find  some  safer  and  simpler  methods  than 
those  at  present  practised,  hysterectomy  for  uterine  myomata 
will  only  be  employed  for  tumours  which  directly  threaten  life. 

It  has  been  for  many  years  the  custom  to  remove  the 
pedunculated  submucous  myoma  which  is  known  as  a  uterine 
polypus ;  many  of  these  possess  narrow  stalks,  Avhich  simply 
require  detaching  with  very  little  more  ceremony  than  a 
gardener  detaches  a  ripe  pear.  Others  have  broad  bases  and 
require  enucleation — a  troublesome  and  often  dangerous  process 
which  is  being  gradually  abandoned  in  favour  of  hysterectomy. 

The  removal  of  a  uterus  containing  a  large  myoma  through 
an  incision  in  the  abdominal  wall  is  a  serious  proceeding,  but 
fortunately  there  is  an  alternative  which  is  often  as  useful  as 
hysterectomy,  but  far  less  dangerous.  It  has  already  been 
mentioned  that  some  myomata  shrink  and  ultimately  dis- 
appear, and  many  others  cease  to  grow  after  the  menopause. 
Taking  advantage  of  this  fact,  surgeons  often  artificially 
accelerate  the  menopause  by  removing  the  ovaries  and  Fallo- 
pian tubes  (oophorectomy). 

This  operation  has  now  been  carried  out  in  a  large  number 
of  cases  with  admirable  results,  and  its  effect  in  causinsf  the 
disappearance  of  tumours  reaching  even  to  the  umbilicus  is 
often  astonishing,  and  the  rapidity  of  the  shrinking  is  equally 
remarkable.  Unfortunately  this  method  is  not  applicable  to 
all  cases,  for  in  many  the  tubes  and  ovaries  are  sometimes  so 
implicated  in  the  tumour,  or  crowded  into  inaccessible  posi- 
tions, that  they  cannot  be  removed,  and  if  the  least  piece  of 
ovarian  tissue  is  allowed  to  remain  it  will  nullify  the  opera- 
tion ;  in  the  case  of  large  tumours  the  broad  ligaments  are  so 
stretched  that  the  ligatures  slip  from  the  pedicles.  Often  the 
ovary  on  one  side  can  be  removed,  but  not  on  the  other; 
hence  many  operations  undertaken  with  the  view  of  oophorec- 
tomy terminate  in  hysterectomy.  It  is  for  this  reason  that 
uterine  myomata  are  not,  as  a  rule,  subjected  to  surgical 
treatment  unless  they  threaten  life  directly  or  indirectly. 

The  practice  generally  adopted  may  be  summarised  thus  : — 

1.  A  myoma  is  the  cause  of  serious  and  repeated  haemor- 
rhage producing  profound  anaemia ;  the  bleeding  is 
uninfluenced  by  rest  and  the  administration  of  ergot. 

K 


146  GONNECTIVI<J    TIHHUE    TUMOUIiH. 

These  signs  may  be  due  to  a  pedunculated  inyorna ;  this 
should  be  removed  without  delay.  When  the  tumour  is  small 
it  may  be,  and  often  is,  necessary  to  dilate  the  cervical  canal. 
When  no  such  cause  exists  and  the  menopause  cannot  be 
expected  for  some  years,  then  ooj^horectomy  should  be  carried 
out,  and,  failing  this,  hysterectomy,  if  the  anatomical  conditions 
be  favourable. 

2.  A  myoma  of  moderate  size,  in  a  woman  between  thirty 
and  forty-five  years,  becomes  impacted  so  as  to  cause 
retention  of  urine  at  each  menstrual  epoch. 

Such  a  case  demands  oophorectomy,  which  is  usually  an 
easy  and  safe  proceeding  in  these  circumstances.  The  operation 
is  advised  to  prevent  the  kidneys  becoming  hydronephrotic. 

The  following  conditions  demand  hysterectomy  : — 

1.  A  myoma  rapidly  increasing  in  size  and  extending  high 

above  the  pelvic  brim  causes  intestinal  obstruction 
by  pressing  on  the  colon  at  the  brim  of  the  pelvis. 

2.  A  myoma  that  rapidly  enlarges  after  the  menopause  ; 

such  a  tumour  is  a  rarity,  but  it  is  a  reality. 

3.  A  myoma  that  has  given  little  trouble  suddenly  begins 

to  enlarge,  accompanied  by  rapid  pulse,  high  tem- 
perature, and  signs  of  septicaemia ;  this  indicates 
septic  infection  of  the  tumour. 

It  occasionally  happens  that  an  operator  opens  an  abdomen 
under  the  impression  that  he  is  dealing  with  an  ovarian 
tumour.  In  such  circumstances  it  is  his  duty  to  perform 
oophorectomy  if  practicable.  Sometimes  large  subserous 
pedunculated  myomata  simulate  ovarian  tumours  ;  such  may 
be  easily  dealt  with  by  tying  the  pedicles  and  cutting  awa}^ 
the  tumours. 

Myomata  of  the  Broad  Ligament. — Large  tumours  of  the 
kind  represented  in  Fig.  73  have  in  many  instances  been 
enucleated.  The  operation  is  very  tedious,  difficult,  and 
dangerous ;  more  than  half  the  patients  die. 

Myomata  of  the  Rovmd  Ligament. — The  removal  of  these 
tumours  is  devoid  of  risk. 

Ovarian  Myomata. — These  are  treated  on  the  same 
principles  as  ovarian  cysts  and  with  the  same  happy  results. 

Cutaneous  Myomata. — These  are  as  easily  removed  and 
with  as  little  inconvenience  as  fatty  tumours. 


147 
CHAPTER     XVI. 

NEUROMATA. 

A  neuroma  is  a  tuinour  growing  from,  and  in  structure  re- 
seinblino;,  the  sheatli  of  a  nerve.  The  genus  neuroma  contains 
three  species  : — 

1.  Neuro-fibroma. 

2.  Plexiform  neuroma. 
8.  Traumatic  neuroma. 

1.  Neuro-fibromata. — A  neuroma  of  this  species  is  usually 
fusiform,  and  grows  from  the  side  of  a  nerve.  When  large  it  will 
spread  out  the  fasciculi  of  the  nerve  like  a  strap;  exceptionally 
the  nerve  will  traverse  the  neuroma.  As  a  rule,  the  long  axis 
of  the  tumour  coincides  with  that  of  the  nerve  from  which  it 
grows. 

In  size,  neuro-fibromata  vary  greatly ;  some  are  no  larger 
than  lentils,  others  may  attain  the  size  of  a  fist ;  larger  speci- 
mens are  exceptional :  they  are  often  multiple,  and  sometimes 
affect  the  nerves  in  almost  every  part  of  the  trunk  and  limbs  ; 
in  other  cases  they  may  be  localised  to  the  nerves  of  a  limb,  or 
even  limited  to  one  nerve. 

Simple  neuromata  occur  on  the  cranial  as  well  as  on  the 
spinal  nerves,  and  grow  on  the  roots,  trunks,  or  terminal 
branches ;  they  form  smooth  swellings,  which  are  mobile,  and, 
when  situated  in  the  subcutaneous  tissue,  glide  easily  under 
the  skin. 

Structurally  neuro-fibromata  consist  of  connective  tissue 
identical  with  that  which  constitutes  the  sheath  of  the  nerve  ; 
they  are  extremely  liable  to  become  myxomatous,  and  in  large 
specimens  this  change  may  lead  to  the  formation  of  cavities  in 
the  tumours.  These  chanofes  account  for  the  various  names 
applied  to  neuromata — such  as  myxoma,  myxo-fibroma,  myxo- 
sarcoma, neuro-myxoma,  and  the  like. 

An  instance  of  a  neuroma  consisting  almost  entirely  of 
myxomatous  tissue  is  represented  nearly  natural  size  in  Fig.  76. 
The  tumour  grew  from  the  infra-orbital  nerve  and  invaded 
the  antrum.  The  surface  of  the  tumour  which  projected  into 
the  antrum  was  covered  with  a  layer  of  mucous  membrane 


148 


(JONNEGTJVE    TLSSUK    TUMOTTRS. 


furnished  with  cihatcd  epitheHimi.  In  this  case  the  tumour 
produced  intense  suffering.* 

The  brandies  of  the  fifth  cranial  nerve  (trigeminal)  are 
often  the  seat  of  neuromata,  and  in  the  majority  of  cases  they 
cause  great  pain.  It  is  a  curious  fact  that  a  neuroma  on  a 
mixed  nerve  is  rarely  painful.  The  tumour  of  the  radial  nerve 
(Fig.  77)  was  painless  except  when  pressed. 

JSTeuromata  form  on  any  of  the  cerebro-spinal  nerves,  but 
they  affect  some  of  the  cranial  nerves  much  more  frequently 
than  others.     Sensory  nerves  seem  more  liable  to  be  attacked 


Fig.  76. — Neuroma  of  the  infra-orbital  nerve  invading  the  antrum.     The  patient  was  a  woman 
twenty-two  years  of  age. 

than  those  that  are  purely  motor.  Mention  has  already  been 
made  of  the  frequency  with  which  the  branches  of  the  trigeminal 
nerve  (fifth)  are  attacked  by  neuromata,  and  it  is  somewhat 
strange  that  the  facial  nerve  (seventh),  which  supplies  an  almost 
identical  territory,  should  so  rarely  develop  tumours  on  its 
sheath.  Hutchinsonf  has  described  a  neuroma  removed  from 
the  facial  nerve  as  it  traversed  the  parotid  gland  by  Warren  Tay. 
A  neuroma  of  the  optic  nerve  is  a  great  rarity.  JocqsJ  has 
written  a  valuable  monograph  based  on  the  records  of  sixty- 
two   cases.      The   clinical  facts    contained    in    the    book    are 

*  Trans.  Clin.  Soc,  vol.  xxiii.  44. 

t  Trans.  Path.  Soc,  vol.  xxxvii.  459. 

J;  "  Des  Tumeurs  du  ISTerf  Optique,"  Paris,  1887. 


NEUROMATA. 


149 


extremely  useful,  but  there  is  little  definite  pathological  in- 
formation. The  tumours  are  classed  mainly  under  five  heads 
— glioma,  myxoma,  myxo-sarcoma,  fibroma  and  sarcoma.  The 
tumours  of  this  nerve  occur  at  any  age,  but  they  are  very  rare 
after  the  twentieth  year.  Most  of  them  are  myxomatous. 
Those  that  occur  in  infants  and  in  old  age  are  probably  sarco- 
mata. There  can  be  little  doubt  that  the  rarity  of  tumours  of 
the   optic  nerve  explains  the  want  of  accurate  histological 


Fif-.  7" 


-Neuro-fibroma  of  the  radial  iiei  ve  at  the  wust,  fioiii  a  female  iiiueteeu  years  old. 
[t  simulated  a  ganglion. 


knowledge  concerning  them,  as  many  ophthalmic  surgeons  of 
very  large  experience  do  not  see  more  than  one  case  in  a  life- 
time. Tumours  of  the  optic  nerve  are  usually  ovoid  in  shape, 
with  their  long  axes  coincident  with  those  of  the  nerve.  Their 
surfaces  are  usually  smooth,  and  in  size  they  vary  greatly,  but 
rarely  exceed  a  pigeon's  egg.  They  do  not  tend  to  invade  the 
globe,  but  they  are  apt  to  creep  through  the  optic  foramen 
and  involve  the  intracranial  portion  of  the  nerve.  As  the 
fibres  of  the  nerve  are  early  implicated,  vision  is  soon  inter- 
fered with ;  there  is  proptosis,  but  the  movements  of  the  eye 
are  free,  and  there  is  no  pain,  even  on  manipulation. 

Neuromata  have  been  observed  on  the  auditory  nerve 


150  CONNECTIVE    TISSUE    TUMOURS. 

within  the  internal  auditory  meatus.  Toynbee*  has  recorded 
some  examples.  In  each  instance  the  patients  suffered  from 
slowly  increasing  deafness. 

Neuromata  occur  on  the  roots  of  the  spinal  nerves.  When 
large,  a  neuroma  in  this  situation  may  so  press  upon  the  cord 
as  to  induce  paraplegia.  Mr.  Sibley f  recorded  an  example  of  this 
in  1866.  A  man  forty-tive  years  of  age  was  admitted  into  the 
Middlesex  Hospital  with  well-marked  paraplegia.  At  the  post- 
mortem examination  a  large  number  of  small  tumours  was 
found  on  the  roots  of  the  nerves.  Many  of  the  roots  were  so 
beset  with  these  tumours  as  to  resemble  strings  of  beads.  In 
the  cervical  region  there  was  a  tumour  as  large  as  a  nut,  which 
had  compressed  the  cord  and  produced  paraplegia.  There 
was  a  large  neuroma  on  the  anterior  crural  nerve,  and  smaller 
examples  on  the  branches  of  the  lumbar  plexus.  Chavasse| 
has  recorded  a  somewhat  similar  case.  In  this  instance  a  large 
neuroma  springing  from  a  cervical  nerve  formed  a  tumour  m 
the  neck ;  this  was  removed  :  septic  spinal  meningitis  followed, 
ending  in  death. 

Multiple  neuromata  are  sometimes  associated  with  a 
multitude  of  the  small  tumours  of  the  skin  known  as  mol- 
luscum  fibrosum.  We  are  indebted  to  Professor  von 
Keckline^hausen'S  for  formulatino-  our  knowledafe  in  reo^ard  to 
this  combination. 

In  typical  cases  of  molluscum  fibrosum  the  skin  of  the 
trunk  and  limbs  presents  numbers  of  small  tumours,  consisting 
mainly  of  fibrous  tissue  springing  from  the  subcutaneous  con- 
nective tissue.  These  tumours  are  of  various  sizes,  some  being 
no  larger  than  a  pin's  head,  whilst  many  are  as  big  as  a  filbert, 
and  a  few  even  larger.  The  majority  are  about  the  size  of 
a  small  pea.  Many  are  sessile,  and  others  are  distinctly 
pedunculated,  but  all  are  covered  with  skin.  These  tumours 
are  mobile,  soft  to  the  touch,  and  of  the  consistence  of  fat. 
The  general  appearance  and  distribution  of  these  molluscum 
bodies  are  shown  in  Plate  III. 


*  Trans.  Path.  Soc,  vol.  iii.  49 ;  and  iv.  259,  plate  ix.,  fig.  1. 
+  Medico-Chir.  Trans.,  vol.  xlix.  39. 
X  Medico-Chir.  Trans.,  vol.  Ixix.  517. 

§  "  Die  multiplen  Fibrome  der  Haut  und  ihre  Beziehung  zu  den  multiplen 
Neuromen,"  Berlin,  1882. 


PLATE  III. — Molluscum  Fibrosum  combined  with  Tumours  on  the  Nerves. 

{After  Payne.) 


NEUROMATA.  151 

Prof,  von  Eecklinghausen  was  the  first  clearly  to  detect 
the  association  of  the  two  classes  of  tumours,  and  he  urged 
that  the  molluscum  bodies  of  the  skin  were  formed  on  the 
cutaneous  nerves,  and  were  as  truly  neuromata  as  the  fibrous 
tumours  on  the  epineurium  of  the  deeper  nerves. 

It  has  been  argued  against  this  view,  especially  by  Dr. 
Payne,*  that  some  of  the  molluscum  bodies  contain  no  nerve 
fibrils,  but  appear  to  be  formed  around  other  structures  of  the 
skin,  such  as  glands  and  hair  follicles. 

It  should  be  borne  in  mind  that  in  the  common  form  of 
subcutaneous  neuroma,  the  painfid  suhcufaneous  tubercle, 
no  one  has  yet  succeeded  in  demonstrating  the  presence  of 
nerve  fibrils.     (See  page  50.) 

The  remarkable  case  of  Michael  Lawlor,  described  in 
Smith's  classical  monograph,t  was,  in  all  probability,  an 
example  of  this  combination.  It  was  estimated  that  this  man 
had  at  least  2,000  tumours.  There  were  450  tumours  counted 
on  the  nerves  of  the  right  lower  limb,  and  300  on  the  left. 
There  were  200  tumours  on  the  right  and  100  on  the  left 
upper  limb.  The  pneumogastric  nerves  and  their  branches 
possessed  60  tumours,  some  of  large  size.  The  remainder 
were  on  the  trunk. 

2.  Plexiform  Neuromata. — This  species  of  neuroma  is,  in 
comparison  with  the  preceding,  somewhat  rare.  Instead  of 
forming  distinct  tumours,  as  is  the  case  with  simple  neuro- 
mata, it  seems  as  if  the  branches  of  a  nerve  distributed  to 
a  particular  area  of  the  skin  become  enlarged  and  elongated. 
The  result  is  that  the  skin  overlying  them  becomes  stretched, 
thinned,  and  raised  over  the  thickened  nerves. 

When  the  tumour  is  examined  it  feels  like  a  loose  bag 
containing  a  number  of  tortuous,  irregular  vermiform  bodies, 
soft  to  the  touch  and  mobile :  they  vary  in  thickness  from  a 
crow-quill  to  that  of  the  thumb  ;  manipulation  produces  no 
pain.  When  the  skin  covering  the  tumour  is  reflected  these 
elongated  bodies  will  be  found  to  lie  in  the  direction  of  the 
nerve  of  the  part ;  thus  on  the  scalp  they  will  run  towards 
the  vertex ;  on  the  back  their  direction  will  be  transverse,  and 
so  on. 

*  Trans.  Clin.  Soc,  vol.  xxii.,  p.  189  ;  and  Trans.  Path.  Soc,  vol.  xxxviii.,  69. 
t  "ISTeuroma,"  1849. 


152 


GONNEGTfVE    TISSUE    TUMOimS. 


On  section  the  nerve  has  an  appearance  hke  an  nin- 
biheal  cord,  due  to  the  presence  of  a  large  quantity  of 
myxomatous  tissue  replacing  the  sheath  of  the  nerve. 

Plexiform  neuromata  are,  as  a  rule,  congenital ;  in  the  case 


Fig.  78.— Plexiform  neuroma  from  tlie  back  of  a  youth  nineteen  years  of  age. 
I^Aftar  Bruns.*) 

represented  in  Fig.  78  the  skin  covering  the  tumour  was  the 
seat  of  a  brown  mother-mark. 

Campbell  cle  Morgan  published  the  details  of  a  remarkable 
plexiform  neuroma  implicating  the  musculo-spiral  nerve  and 
its  branches  in  the  forearm.      The  patient,  a  young  lady,  had 

*  Beitrcige,  bd.  viii.,  s.  i. 


NEUROMATA. 


153 


an  irregular  swelling  extending  from  the  palm  of  the  hand  to 
the  elbow.  (Fig.  79.)  This  sweUing  felt  like  strings  of  beads  ; 
it  was  not  painful  except  when  pressed.  The  patient  was 
under  observation  seven  years,  and  as  the  tumour  continued 
to  increase,  the  arm  was  amputated. 

On  dissection  the  musculo-spiral  nerve  was  found  to  be  as 
thick  as  the  thumb  ;  it  looked  gelatinous,  like  an  umbilical 
cord,  and  as  it  passed  under  cover  of  the  brachio-radialis 
muscle  it  entered  a  neuroma  as  large  as  an  egg.  The  radial 
and  cutaneous  branches  issued  from  this  tumour  as  thick, 
irregularly  nodulated  trunks.     (Fig.  80.) 

Malignant  Neuromata. — Although  the  majority  of  tumours 


Fig.  79. — Arm  in  wliich  tlie  innsculo-spiral  nerve  was  neuromatous. 
{After  Campbell  cle  Morgan.) 

which  originate  in  the  connective-tissue  sheaths  of  nerves  are 
either  fibromata  or  myxomata,  yet  now  and  then  tumours 
arise  from  nerve-trunks  which  in  their  clinical  behaviour,  as 
well  as  in  structure,  are  sarcomata,  and,  as  a  rule,  belong  to 
the  spindle-celled  species  ;  such  tumours  are  sometimes  called 
malignant  neuromata.  Balding*  has  given  an  account  of  a 
case  in  which,  he  removed  a  tumour  of  this  kind  from  the 
great  sciatic  nerve  of  a  man  thirty  years  old ;  it  quickly  re- 
turned, general  dissemination  followed,  and  the  man  died. 

Lawson  t  has  published  an  example  of  a  round-celled 
sarcoma  springing  from  the  sheath  of  the  optic  nerve  in  a 
man  sixty-five  years  of  age.  The  eye  and  nerve  were  excised  ; 
there  was  recurrence  ancl  death  in  three  months. 

*  Trans.  Path.  Soc,  vols,  xxvii.  and  xxviii.  2a. 
t  Ophth.  Hosp.  Eep.,  Lond.,  1882,  p.  296. 


154 


CONNECTIVE    TISSUE    TUMOUIiS. 


3.  Traumatic  Neuromata. — After  a  nerve  has  Ijeen  divided, 
the  proximal  end  becomes  enlarged  and  forms  an  oval  bidb. 
A  drawing  made  from  a  dissection  of  the  stump  left  after 


Musculo-spiral  nerve. 


Biacliio-radialis  muscle 
(Supinator  longus). 


Neuromata  on  the  cutaneous 

branches  of  the   musculo- 
spiral  nerve. 


Fig.   SO.— The  arm  represented  in  the  iieceduig'  h^uie  dissected;   the  musculo-spiral  nerve 
and  its  branches  are  transformed  into  a  ple\ifoim  neuioma     (Museum,  Middlesex  Hospital.) 

amputation  through  the  forearm,  three  years  previously,  is 
shown  in  Fig.  81.  The  median,  musculo-spiral,  and  ulnar 
nerves  terminate  in  bulbs. 

These  curious  bulbs  are  nearly  always  found  in  amputation 


IsEUROMATA. 


155 


stumps.  In  size  they  bear  little  relation  to  the  nerves  on  which 
they  occur,  for  a  bulb  on  the  cut  end  of  a  saphena  nerve  may 
in  some  cases  be  as  large  as  one  on  the  cut  end  of  the  external 
popliteal  in  the  same  stump.  The  bulbs  form  rapidly,  and  will 
sometimes  attain  the  size  of  a  cherry-stone  on  a  cut  ulnar 
nerve  in  the  space  of  six  weeks.  Recently-formed  bulbs  con- 
sist of  connective  tissue  intermixed  with  nerve  fibres  in  various 
stages  of  degeneration,  but  old  examples  rarely  contain  nerve 
fibrils,  and  are  often  as  dense  as  cicatricial  tissue. 


Median  nerve. 


Ulnar  nerve. 


Fig.  81.— Dissection  of  a  stump  of  the  forearm  three  years  after  amputation,  to  show  the 
bulbs  on  the  ends  of  nerves.     (Museum,  Middlesex  Hospital.) 

There  is  reason  to  believe  that  bulbs  are  larger  in  cases 
where  suppuration  has  been  profuse  and  healing  long  delayed; 
also  when  the  nerves  have  become  adherent  to  bone  or  incor- 
porated in  the  cicatrix.  In  many  examples  it  is  probable  that 
the  end  of  the  nerve  has  been  included  in  a  ligature  applied  to 
an  artery. 

The  size  of  the  bulb  has  little  influence  on  the  pain  felt  in 
a  stump.  In  some  instances,  where  pain  is  so  intense  as  to 
necessitate  re-amputation,  only  small  bulbs  exist.  In  the 
case  of  the  stump  represented  in  Fig.  81  even  firm  pressure  on 


156  CONNECTIVE    TIHSUE    TUMOURS. 

the  bulbs  failed  to  produce  evidence  of  pain.  Stumps  are  more 
often  troublesome  from  this  cause  in  females  than  in  males. 

Similar  bulbs  occur  in  other  mammals  and  birds  after  the 
accidental  ablation  of  limbs  by  traps,  guns,  or  Ijites  from  other 
animals.  These  bulbs  are  sometimes  painful  when  pressed, 
particularly  on  the  stumps  of  the  tails  of  dogs  that  have  been 
docked.  Bulbs  form  on  the  proximal  ends  of  divided  nerves 
independently  of  amputation,  as  dissections  of  the  nerves 
in  the  legs  of  horses  that  have  been  submitted  to  neurotomy 
demonstrate.  When  nerves  are  injured  by  brittle  substances, 
such  as  glass,  slate,  and  the  like,  small  fragments  some- 
times become  embedded  in  the  nerve  and  cause  excessively 
painful  bulbs  to  form. 

Clinical  Features. — Neuromata  are,  in  the  majority  of 
cases,  innocent  tumours  ;  they  very  rarely  recur  or  become 
disseminated;  nevertheless  they  are  in  exceptional  cases  the 
cause  of  death.  A  large  intracranial  neiu'oma  will  produce 
fatal  pressure  on  the  brain,  and  several  cases  are  recorded  in 
which  small  neuromata  of  the  spinal  nerve  roots  have  caused 
paraplegia  and  death.  Smith*  refers  to  a  case  in  which  a 
woman  complained  of  severe  pain  in  the  course  of  the  right 
trigeminal  nerve ;  this  pain  was  so  much  increased  by  masti- 
cation that  she  ate  but  little,  and  speaking  aggravated  it 
to  such  a  degree  that  she  always  remained  silent  unless  inter- 
rogated, and  even  on  these  occasions  she  frequently  replied  by 
signs.  She  died  after  enduring  severe  and  uninterrupted  pain 
during  four  and  a  half  months.  At  the  autopsy  a  neuroma  as 
large  as  a  walnut  occupied  the  situation  of  the  right  Gasserian 
ganglion. 

The  pain  produced  by  pressing  a  painful  subcutaneous 
tubercle  has  already  been  considered.  When  the  roots 
of  the  spinal  nerves  are  involved  in  a  neuroma,  pain  is  a 
prominent  symptom,  but  is  not  confined  to  this  class  of 
tumom\ 

Treatment. — A  solitary  neuroma  in  an  accessible  position 
is  easily  removed.  •  When  seated  upon  a  large  nerve  trunk, 
especially  if  it  contain  motor  fibres,  care  must  be  exercised 
to  avoid  damage  to  the  nerve.  In  many  cases  the  tumour 
can  be  separated  without  injury  to  the  nerve  :  it  occasionally 

*  "Neuroma,"  p.  120. 


NEUROMATA.  157 

happens  that  the  neuromatous  nature  of  the  tumour  is  not 
recognised  until  after  its  removal  Avith  a  portion  of  the  nerve. 
In  the  limbs  such  breaches  in  the  continuity  of  nerves  have 
been  repaired  by  grafting  fragments  of  nerves  from  amputated 
limbs  or  from  rabbits ;  it  is,  however,  always  better  to  avoid 
the  accident  by  careful  surgery  than  to  remedy  it  by  secondary 
measures,  however  brilliant.  Persistent  facial  palsy  has 
followed  removal  of  a  neuroma  lodged  in  the  parotid  gland. 
Neuromata  within  the  spinal  canal  have  been  successfully 
removed.  A  neuroma  of  the  optic  nerve  usually  necessitates 
excision  of  the  eyeball. 

Multiple  neuromata,  and  especially  those  associated  with 
molluscum  fibrosum,  are  bevond  the  reach  of  surgical  art. 

Plexiform  neuromata  have  been  several  times  successfully 
removed ;  exceptionally,  when  affecting  the  nerves  of  a  limb, 
amputation  has  been  necessary. 

Traumatic  neuromata,  when  painful  in  an  amputation 
stump,  are  best  treated  by  removal.  When  an  important  limb 
nerve  has  been  divided,  its  union  is  brought  about  by  joining 
the  cut  ends  with  sutures.  Often  the  injury  to  the  nerve  is 
overlooked  until  the  wound  is  cicatrising ;  it  is  then  necessary 
to  expose  the  gap  in  the  nerve  and  vivify  the  ends  of  the 
nerve  and  unite  them  with  suture.  When  the  gap  is  very 
extensive,  nerve-grafts  may  be  requisite  to  effect  the  repair. 
Worner*  has  published  the  records  of  a  case  in  which,  after  a 
gunshot  wound  of  the  head,  without  injury  to  the  bone  or 
brain,  a  traumatic  or  scar-neuroma  (narben-neurom)  formed  on 
the  occipital  nerve.  The  patient  afterwards  suffered  for 
years  from  epileptiform  seizures.  The  neuroma,  which  was 
as  large  as  a  pea,  was  excised,  and  the  tits  stopped. 

Ganglionic  Neuroma. — Tumours  sometimes  occur  in  the 
brain  composed  of  ganglion  cells,  nerve  fibrils,  and  neuroglia. 

Klebsf  describes  a  neuroma  of  this  species  which  grew 
from  the  floor  of  the  fourth  ventricle  near  the  calamus 
scriptorius ;  the  tmnour  was  nearly  as  large  as  a  walnut. 
He  gives  two  good  drawings  to  illustrate  its  histological 
characters.  Possibly  some  brain  tumours  described  as 
gliomata  were  ganglionic  neuromata. 

*  Bruns,  Beitrdge,  bd.  i.  506. 

t  Allgemeine  Pathologische  Morphologie,  bd.  ii.  795,  1889. 


158 


CHAPTER     XVII. 

ANGEIOMATA. 


An  angeioma  is  a  tumour  composed  of  an  abnormal  formation 
of  blood-vessels. 

This  genus  contains  three  species: — 1,  Simple  nsevus ;  2, 
cavernous  ntevus  ;  3,  plexiform  angeioma. 

1.  Simple  Nsevus. — This  is  the  most  common  sj)ecies  of 
nsevus,  and  in  its  typical  form  aflects  the  skin  and  subcu- 
taneous tissue.  There  are  three  varieties.  A  na^vus  may- 
appear  as  a  superficial  discolouration  of  the  skin,  and  is  either 
a  lively  pink  or  a  deep  blue :  these  are  knoAvn  as  "  port-wine 
stains."  Such  neevi  may  involve  an  area  of  skin  2  cm.  square, 
or  extend  over  a  large  portion  of  the  face,  or  half  the  trunk, 
or  be  restricted  to  a  limb. 

A  very  frequent  form  of  nfevus  is  that  often  referred  to  as 
teleangeiectasis ;  it  consists  of  an  abnormal  collection  of  arte- 
rioles situated  in  the  skin  and  subcutaneous  tissue ;  it  may 
be  present  at  birth,  but  much  more  frequently  appears 
in  the  course  of  the  first  few  weeks  of  life.  Sometimes 
a  neevus  appears  as  a  red  spot  no  larger  than  a  split  pea,  then 
suddenly  it  groAvs  actively,  and  in  two  or  three  months  will 
involve  an  area  of  skin  4  cm.  square.  When  the  nsevus 
consists  of  arterioles  it  will  be  of  a  bright  pink  colour ;  when 
composed  mainly  of  venules  it  will  be  of  a  bluish  tint. 
Lymphatics  are  often  present.  Structurally  na3vi  are  composed 
of  minute  blood-vessels  embedded  in  fat ;  usually  two  or  more 
large  vessels  establish  a  communication  between  the  nsevus  and 
an  adjacent  artery  or  vein.  The  vessels  of  the  nsevus  are  often 
sacculated.  When  gently  compressed,  the  blood  is  driven 
from  the  nasvus,  which  at  once  loses  its  colour,  but  the  colour 
returns  as  soon  as  the  pressure  is  relieved. 

Simple  ntevi  are  common  enough  in  the  skin  of  the  face, 
scalp,  neck,  and  back.  They  are  less  frequent  on  the 
limbs.  They  also  occur  on  the  labium,  the  lips,  tongue,  and 
conjunctiva. 

NiBvi  of  small  size  frequently  disappear  spontaneously ; 


ANGELOMATA.  159 

more  often  they  gradually  increase  in  size,  and  many  become 
converted  into  cavernous  ntevi. 

2.  Cavernous  Nsevus. — This  is  the  variety  to  which  the  term 
erectile  tumour  is  in  all  fairness  applicable.  In  structure  it  is 
comparable  to  the  spongy  tissue  characteristic  of  the  cavernous 
and  spongy  bodies  of  the  penis.  Cavernous,  like  simple  naevi, 
are  most  frequently  seen  in  connection  with  the  skin,  where 
they  form  distinct  tumours  of  a  red  or  blue  colour,  rising  above 
the  general  surface :  sometimes  they  display  the  peculiar  tint 
so  characteristic  of  fluid  contained  in  thin-walled  cysts,  for 
which  a  cavernous  ntevus  is  often  mistaken,  especially  when 
situated  near  the  outer  angle  of  the  orbit.  In  most  cases  the 
blood  can  by  firm  and  steady  pressure  be  squeezed  out  of  a 
nsevus,  but  the  swelling  quickly  reappears  after  the  compres- 
sion is  removed.  The  surface  of  a  nsevus  may  be  over-warm, 
and  sometimes  the  tumour  pulsates,  the  movement  being 
appreciable  to  the  finger,  and  occasionally  perceptible  to  the 
eye. 

Structurally,  cavernous  nasvi  are  made  up  of  variously- 
shaped  spaces  and  sinuses,  the  walls  of  which  are  merely 
fibrous  septa,  lined  with  endothelium.  Some  of  these  nsevi 
consist  in  part  of  vessels  and  in  part  of  cavernous  spaces. 
When  an  angeioma  consists  entirely  of  irregular  blood- 
containing  spaces  a  dissection  around  its  periphery  will  reveal 
the  existence  of  vessels,  sometimes  of  considerable  size,  con- 
veying blood  to  it  from  adjacent  arteries.  Cavernous,  like 
simple  nsevi,  are,  as  a  rule,  congenital,  but  a  nsevus  which 
during  infancy  is  small  and  inconspicuous  may  later  in  life 
become  converted  into  a  cavernous  nsevus  of  large  size,  and 
one  that  will,  under  certain  conditions,  jeopardise  life.  A 
good  examjDle  of  this  came  under  my  care  in  a  lad  seventeen 
years  of  age.  It  appeared  that  as  a  child  he  had  an  ordinary 
nsevus  of  small  size  in  the  skin  above  the  left  nipple.  For 
many  years  this  gave  no  trouble,  then  gradually  increased  in 
size  until  the  mamma  was  converted  into  a  cavernous  nsevus 
8  cm.  in  diameter.  At  intervals  the  surface  ulcerated,  and  pro- 
fuse hsemorrhages  Avere  the  consequence  ;  these  greatly  reduced 
the  boy's  health,  and  rendered  him  profoundly  ansemic* 
I    successfully    excised    the    tumour.     Nsevi  of  the  mammse 

*  Trans.  Clin.  Soc,  a^oL  xxii.,  187 


160  CONNECTIVE    TISSUE    TUMOURS. 

of  children  or  adults  are  very  rare.*  An  extraordinary  case 
illustrating  the  size  to  which  a  cavernous  naivus  of  the  breast 
may  attain,  and  its  dangers,  is  that  reported  by  Image. t 

Cavernous  nfevi  occasionally  occur  in  the  tongue  ;  as  a  rule 
they  are  situated  near  the  surface,  and  form  slightly  elevated 
patches  of  a  deep  blue,  or  livid  colour.  Such  nsevi  rarely  give 
rise  to  any  difficulty  in  diagnosis,  their  colour,  general  appear- 
ance, and  the  fact  that  lirm  pressure  suffices  to  drive  the 
blood  out  of  the  tumour  are  sufficient  to  indicate  their  na^void 
character.  Many  lingual  neevi  are  congenital,  but  a  fair 
proportion  originate  late  in  life.  It  must  also  be  borne  in 
mind  that  a  small  and  inconspicuous  nfevus  may,  as  years 
run  on,  develop  almost  silently  into  a  dangerous  erectile 
tumour.  When  a  cavernous  nsevus  is  situated  deeply  in  the 
substance  of  the  tongue  its  recognition  may  be  difficult  and, 
before  operation,  almost  impossible. 

In  some  instances  lingual  naevi  cause  very  little  incon- 
venience unless  they  bleed,  and  this  accident  may  arise  at  any 
time,  either  by  abrasion  from  hard  food  or  from  accidental 
bites,  or  in  consequence  of  rubbing  against  jagged  teeth. 
Under  such  conditions  the  haemorrhage  is  sometimes  very 
alarming,  and  so  oft-repeated  that  it  is  in  some  instances  im- 
perative to  excise  the  implicated  half  of  the  tongue.  Except 
in  the  tongue  and  rectum,:]:  cavernous  nse\i  are  very  rare  in 
mucous  membranes. 

Cavernous  angeiomata  are  sometimes  found  in  voluntary 
muscles.  Several  interesting  examples  were  collected  and  de- 
scribed by  Campbell  de  Morgan  §  in  1864.  A  case  under  his 
care  occurred  in  the  semi-membranosus  of  a  girl  ten  j'ears  old : 
the  tumour  had  been  noticed  at  birth,  but  as  it  increased  in 
size  it  Avas  removed.  The  child  recovered.  The  histology  of 
the  tumour  was  carefully  investigated  by  Hulke,  who  found  it 
to  exhibit  a  characteristic  cavernous  structure.  This  specimen 
and  others  considered  in  de  Morgan's  paper  are  preserved  in 
the  museum  of  the  Middlesex  Hospital. 

A  cavernous  na3vus  from  the  semi-tendinosus  muscle  is 

*  Brj-ant,  "  Diseases  of  the  Breast,"  p.  345. 

t  Med.-Chir.  Trans.,  vol.  xxx.,  105. 

+  Barker,  Med.-Chir.  Trarjs.,  vol.  Ixvi.,  229. 

§  £7ii.  and  For.  Med.-Chir.  Eevietv,  1864,  p.  187. 


ANGEIOMATA.  161 

preserved  in  the  museum  of  St.  Bartholomew's  Hospital. 
Holmes  Coote  excised  one  from  the  deltoid  of  a  little  girl ; 
in  this  instance  the  swelling  was  congenital. 

Liston*  removed  an  erectile  tumour  from  the  popliteal 
space  of  a  boy  ten  years  of  age.  At  the  operation  it  seemed 
to  be  closely  associated  with  the  semi-membranosus  muscle. 
Attention  was  first  attracted  to  the  tumour  when  the  child  was 
two  years  old ;  during  the  succeeding  eight  years  it  slowly  but 
gradually  increased  in  size.  At  the  age  of  three  years  the 
tumour  distinctly  pulsated,  and  was  as  large  as  a  turkey's  egg. 

Cavernous  angeiomata  are  of  very  rare  occurrence  in  the 
larnyx ;  nevertheless  they  have  been  observed  in  this  situation, 
and  the  careful  descriptions  of  some  of  the  cases  place  the 
nature  of  the  tumour  beyond  doubt.  They  have  been  observed 
springing  from  the  vocal  cords,t  the  ventricular  bands,  and 
from  the  ventricle.  The  most  striking  examples  arise  in  the 
sinus  pyriformis. 

Usually  such  tumours  are  sessile,  but  are  occasionally 
pedunculated  ;  they  may  be  bright  red  or  purple  in  colour. 
The  surface  of  the  tumour  may  be  smooth  or  nodulated  like  a 
mulberry;  they  are  rarely  larger  than  a  haricot  bean.  The 
colour  of  the  tumour  is  its  most  strikino^  clinical  feature. 

An  extremely  rare  situation  for  a  cavernous  n?evus 
is  the  subperitoneal  tissue.  Lane  J  has  described  an  extra- 
ordinary example. 

The  liver  is  not  an  uncommon  situation  for  cavernous  nsevi 
of  small  size.  Nasvi  are  not  uncommon  in  the  livers  of  cats 
and  feline  mammals  in  general,  but  they  appear  to  be  harm- 
less tumours. 

There  is  reason  to  believe  that  cavernous  nsevi  sometimes 
undergo  degenerate  changes  and  become  converted  into  cysts. 
{See  Chapter  on  Nee  void  and  Lymphatic  Cysts.) 

3.  Plexiform  Angeiomata. — The  species  of  angeiomata 
which  wiR  be  included  under  this  denomination  are  those 
usually  designated  as  "  aneurisms  by  anastomosis  "  or  "  cirsoid 
aneurisms."  The  former  term  appears  to  have  been  introduced 
by  John  Bell,  but  the  expression  "  aneurism  by  anastomosis  " 

*  Med.-Chir.  Trans.,  vol.  xxvi.,  p.  120. 
t  Percy  Kidd,  Trans.  Clin.  Soc,  Lond.,  vol.  xxv.,  307. 
J  Trans.  Clin.  Soc,  vol.  xxvi. 
L 


162  CONNECTIVE    TISSUE    TUMOURS. 

has  coiTie  to  be  used  so  vaguely  that  its  suppression  is  a 
matter  of  necessity. 

A  plexiform  angeioma  consists  of  a  nuniljer  of  abnormal 
blood-vessels  of  moderate  size  arranged  parallel  to  each  other, 
as  in  the  rete  mirabile  of  the  fore-liml)  of  the  sloth,  or  the 
tail  of  a  spider  monkey.  Such  angeiomata  may  consist  of 
arteries  only,  as  in  arterial  retia,  or  of  veins,  or  of  arteries  and 
veins  in  equal  proportions  as  in  duplex  retia.  In  some  the 
vessels  are  very  tortuous,  a  disposition  is  more  common 
with  arteries  than  veins.  Tortuous  vessels  are  not  infrequent 
in  retia — for  example,  the  arterial  retia  in  the  intercostal 
spaces  beneath  the  pleura  of  cetaceans,  and  in  the  pituitary 
fossae  of  oxen  and  sheep,  and  renal  glomeruli. 

Plexiform  angeiomata  are  very  rare ;  the  largest  that 
has  come  under  my  notice  occurred  in  the  perineum  of  a  lad 
nineteen  years  of  age  ;  the  corpus  spongiosum  was  surrounded 
by  a  number  of  arteries  as  large  as  the  coronary  branches  of 
the  facial,  and  veins  as  big  as  the  cephalic.  The  arrangement 
resembled  that  of  a  duplex  rete. 

Barwell*  has  given  a  very  careful  clinical  history,  accom- 
panied by  a  description  of  the  dissection  of  the  limb,  in  which 
a  plexiform  angeioma  involved  the  arteries  and  veins  in  the 
forearm  of  a  man  twenty-one  years  of  age.  In  this  case  the 
superficial  veins  and  the  muscular  branches  of  the  arteries 
Avere  more  particularl}^  involved. 

Mtillert  has  recorded  very  carefully  the  clinical  history 
and  an  account  of  the  subsequent  dissection  of  a  very  unusual 
example  of  plexiform  angeioma.  The  patient,  a  man  of  twenty 
years,  stated  that  his  parents  noticed  a  red  spot  on  the  left 
half  of  the  forehead  when  he  was  a  year  old  ;  this  gradually 
increased  in  size,  and  at  the  asfe  of  twelve  it  had  become  an 
obvious  tumour.  When  the  patient  was  sixteen  it  not  only 
grew  rapidly,  but  began  to  "  buzz."  At  the  age  of  twenty  the 
tumour  exhibited  all  the  characters  of  a  plexiform  angeioma, 
the  pulsation  being  attended  by  a  whirring  sound.  There 
was  obvious  hypertrophy  of  the  left  ventricle  of  the  heart. 

P.  Bruns  ligatured  the  right  external  carotid  and  the 
left     common    and    external   carotid.      The   patient    became 

*  Trans.  Path.  Soc,  vol.  xxxviii.,  p.  121. 
t  Bruns,  Beitragc,  bd.  viii.  79. 


ANGEIOMATA. 


163 


liemiplegic  on  the  second,  and  died  on  the  third  day  after 
the  operation.  Death  Avas  due  to  embohsm  and  thrombosis  of 
the  left  middle  cerebral  artery.  The  parts  were  injected  and 
dissected.  As  shown  in  Fig-.  82,  the  angular  arteries  were  of 
colossal  size  and  very  tortuous. 

Treatment. — This     varies    Avith     the     character    of    the 
angeioma ;  for  instance,  the  diffuse  species  known  as  "  port- 


Fig,  82.-  Dissecticjn  of  a  plexiform  angeioma  of  the  forehead.    {After  II.  iMiiUcr.) 


wine  staining,"  when  extensive,  does  not  admit  of  treatment, 
but  a  stain  of  this  character  the  size  of  a  crown-piece  may  be 
successfully  destroyed  by  electrolysis  when  it  occurs  in  a 
conspicuous  situation.  The  common  species  of  nsevus  comes 
under  observation  almost  daily ;  in  such  cases  it  is  usual  to 
watch  the  child  in  order  to  ascertain  whether  the  npevus  is 
growing  or  not ;  many  naevi  disappear,  but  when  they  become 
active  and  grow,  they  need  prompt  treatment.  No  method  is 
so  safe  and  effectual  as  excision,  whenever  it  can  be  carried 


164  GONNE(JTIVK    TISSUE    TUMOURS. 

out,  remembering  always  to  cut  the  naevus  out,  not  cut 
into  it.  I  have  excised  nsevi,  simple  and  cavernous,  from  the 
skm  over  an  unclosed  fontanelle,  the  eyelids,  the  tongue, 
labium,  and  other  parts  of  the  body  in  more  than  one  hundred 
children,  and  never  had  the  least  untoward  symptom.  It  is 
infinitely  preferable  to  treatment  by  electrolysis,  nitric  acid, 
ethylate  of  sodium,  and  the  ligature.  The  chief  reason  for 
excising  nsevi  when  they  evince  signs  of  activity  is  to  prevent 
them  from  assuming  such  proportions  as  to  pass  beyond 
the  limits  of  justifiable  surgery.  Many  examples  have  been 
recorded  in  which  a  nsevoid  fleck  in  an  infant  has  become  a 
formidable  tumour  in  the  adult. 

It  is  impossible  to  advise  in  regard  to  the  treatment  of 
plexiform  angeiomata.  Each  case  exhibits  special  features 
which  will  modify  the  operation,  and  the  particular  method 
employed  will  depend  on  the  enterprise,  experience,  and  skill 
of  the  surgeon  in  charge  of  the  case.  Several  cases  of  plexiform 
ansfeioma  of  the  limbs  have  been  recorded  in  which  it  has 
been  necessary  to  resort  to  amputation.  When  the  leg  is 
involved  this  operation  is  attended  with  unusual  risk  to  life. 

LYMPHANGEIOMATA. 

A  lymphangeioma  has  the  same  relation  to  lymphatics 
that  an  angeioma  bears  to  hfemic  capillaries. 

There  are  three  species  of  lymphangeiomata : — 

(1)  Lymphatic  nsevus ;  (2)  cavernous  lymphangeioma ; 
(3)  lymphatic  cyst. 

1.  Lymphatic  Naevus. — This  species  of  lymphangeioma  is, 
as  a  rule,  colourless,  but  when  containing  a  fair  number  of 
hsemic  capillaries,  then  the  najvus  appears  as  a  pale  pink 
patch  slightly  raised  above  the  level  of  the  surrounding  skin. 
When  composed  entirely  of  lymphatics  it  is  white  in  colour ; 
when  pricked,  lymph,  sometimes  mixed  with  blood,  issues 
from  it.  Occasionally  several  ncevi  occur  in  the  same  in- 
dividual ;  they  vary  greatly  in  size,  some  are  as  small  as  shot, 
others  may  have  a  diameter  of  2  cm.  or  more.  In  many 
instances  they  are  noticed  a  few  months  after  birth,  occa- 
sionally they  seem  to  be  acquired.  This  is  probably  explained 
on  the  ground  that  during  infant  life  they  are  small,  and 


LYMPHANGEIOMATA.  165 

their  want  of  colour  saves  them  from  detection  until  their 
increase  in  size  later  in  life  makes  them  conspicuous. 

Lymphatic  m^Vi  may  occur  in  the  skin  on  any  part  of  the 
trunk  or  limbs,  and  have  been  especially  studied  in  the 
mucous  membrane  of  the  tongue  and  lips. 

In  connection  with  the  tongue  the  affection  may  be 
localised  to  a  definite  area  and  give  rise  to  a  lingual  lymphan- 
geioma ;  this  takes  the  form  of  a  pale  pink  papilla,  or  clusters 
of  smooth  papillse,  projecting  from  the  mucous  membrane. 
Sometimes  one-half  of  the  dorsum  of  the  tongue  will  be  beset 
with  small  rounded  projections.  These  projections  consist 
of  clusters  of  dilated  lymphatic  vessels. 

There  is  a  very  rare  disease  of  the  tongue  to  which  the 
name  macroglossia  is  applied.  Clinically  the  condition  mani- 
fests itself  as  a  congenital  enlargement  of  the  tongue  im- 
plicating mainly  its  anterior  two-thirds.  As  the  child  grows 
the  tongue  increases  so  disproportionately  that  the  mouth 
accommodates  it  with  difficulty,  and  at  last  the  tip  of  the 
organ  protrudes  from  the  mouth  and,  in  severe  examples, 
becomes  so  big  as  to  extend  far  beyond  the  margins  of  the 
lips.  In  the  case  represented  in  Fig.  83  the  large  tongue  pro- 
duced great  deformity  by  everting  the  anterior  portion  of  the 
mandible  and  increasing  the  distance  between  the  teeth 
lodged  in  the  everted  portion. 

The  increase  in  the  size  of  the  tongue  is  not  due  to  an 
overgrowth  of  its  muscular  substance,  but  is  caused,  as  Virchow 
pointed  out,  by  the  formation  of  a  lymphangeioma  in  connec- 
tion with  the  lingual  mucous  membrane. 

2.  Cavernous  Lymphangeiomata. — This  species  in  its 
naked-eye  characters  resembles  a  lymphatic  nsevus,  but  on 
microscopical  examination  it  will  be  found  to  be  identical  in 
structure  with  the  cavernous  nsevus,  with  the  difference  that 
its  cavities  are  filled  with  lymph  instead  of  blood. 

3.  Lymphatic  Cyst. — This  sj)ecies  of  lymphatic  tumour  is 
considered  in  the  section  devoted  to  congenital  cysts  of  the 
neck. 

The  larger  lymphatic  channels,  like  veins,  are  apt  to  become 
varicose  or  form  local  dilatations,  to  which  the  term  lymphatic 
varices  are  applicable.  When  the  lymph  stream  from  a  part 
is  interfered  with,  the  cutaneous  area  drained  by  the  obstructed 


166 


CONNECTIVE    TISSUE    TUMOURS. 


lymphatic  becomes  liard  and  brawny  from  lymphatic  cedema : 
when  a  limb  is  thus  affected  it  gradually  passes  into  the 
enlarged  brawny  condition  known  as  elephantiasis,  of  which 
there  are  many  forms.  It  is,  of  course,  beyond  the  scope  of 
this  work  to  study  diseases  of  lymphatics  in  general,  because 


Fig-.  S3.  — Macroglossia  in  a  girl  aged  eleven  years.    {After  Humphry.*) 

they  run  parallel  with  such  morbid  conditions  of  arteries  and 
veins  as  aneurism,  varix,  thrombosis,  embolism,  and  oedema. 

Treatment. — The  only  species  of  lymphangeioma  the 
treatment  of  which  needs  to  be  considered  is  macroglossia : 
this  condition  produces  such  an  unpleasant  appearance  that  it 
demands  surgical  assistance.  The  method  usually  adopted 
consists  in  the  removal  of  the  protruding  portion  of  the 
tongue. 

*  Humphiy,  Med.-Chir.  Trans,  vol.   xxxvi.,  p.  113;    Barker,  Trans.  Path. 
Soc,  vol.  xli.  77. 


167 


CHAPTER    XYIII. 

GROUP    II.— EPITHELIAL    TUMOURS. 

Ix  the  group  of  tiniiours  now  to  be  considered,  epithelium  is 
not  only  present,  but  is  the  essential  and  distinguishing 
featiu'e.  Epitheliuni  is  so  disposed  in  the  bodies  of  complex 
animals  as  to  serve  many  functions ;  in  some  situations  it  acts 
as  a  protective — e.g.,  the  epidermis,  where  it  becomes  modified 
into  hair,  nail,  horn,  or  into  the  hardest  of  all  animal  tissues — 
enamel ;  in  others,  processes  of  epithelial  cells  dip  into  the 
underlying  connective  tissue  to  form  secreting  glands ;  some  of 
them  are  simple — e.g.,  the  tubular  glands  of  the  intestme;  others 
are  very  complex — e.g.,  the  liver,  mamma,  and  kidney. 
Whether  a  gland  is  simple  or  complex,  the  principle  of  con- 
struction is  identical — namely,  narrow  charmels  Uned  with 
epithelium,  resting  upon  a  connective-tissue  base,  in  which 
blood-vessels,  lymphatics  and  nerves  ramify. 

Each  epithelial  recess  of  a  gland  is  known  as  the  acinus, 
and  each  acinus  is  in  communication  with  a  free  surface,  either 
directly  by  its  own  duct,  as  in  the  case  of  sebaceous  and 
mucous  glands,  or  mdirectly  by  means  of  a  number  of  main 
ducts,  as  in  the  case  of  the  mamma :  or  by  a  common  duct,  as 
in  the  pancreas.  To  this  rule  there  are  three  notable  excep- 
tions :  the  thyroid  gland,  the  pituitary  bod}',  and  the  ovary. 
It  is  important  to  bear  in  mind  the  fact  that,  with  the  three 
exceptions  mentioned,  all  secreting  glands  are  in  direct  com- 
munication with  free  surfaces,  and  are  therefore  accessible  to 
all  kinds  of  micro-organisms. 

The  differences  in  the  disposition  of  epithelium  enable  the 
oncologist  to  arrange  epithelial  tumours  in  four  genera,  the 
species  in  each  genus  being  largely  determined  by  peculiarities 
in  the  shape  or  disposition  of  the  cells : — 

Genera.  Species. 

I.  Papillomata  Skm  warts. 

Tillous  papillomata. 
Intracystic  warts. 
Psammomata. 


168  FA'ITHELIAL    TUMOURS. 

Genera.  SpeeteH. 

II.  Epithelioma.  Epithelioma. 

III.  Adenoma  {Hee  page  219.) 

IV.  Carcinoma  (cancer).  (iS'ee  page  220.) 

PAPILLOMATA. 

A  papilloma  or  wart  consists  of  an  axis  of  iibrous  tissue, 
containing  blood-vessels,  surmounted  by  epithelium,  projecting 
from  a  epithelial-covered  surface ;  it  may  be  simple,  and  pre- 
sent a  uniform  surface,  or  be  so  covered  with  secondary  pro- 
cesses as  to  look  like  a  mulberry.  When  the  processes  are 
long  the  papilloma  has  a  villous  appearance. 

There  are  four  species  of  papiUomata: — 1,  Warts;  2,  villous 
papillomata ;  3,  intracystic  warts ;  4,  psammomata. 

1.  Warts. — Papillomata  of  this  species  are  most  common 
on  the  skm,  but  warts  also  arise  from  mucous  surfaces  covered 
with  squamous  epithelium.  They  occur  singly  or  in  multiples 
and  are  rarely  painful  unless  irritated,  then  they  are  apt  to 
ulcerate  and  bleed.  Crops  of  warts  are  often  seen  on  the  hands 
of  children.  They  are  common  in  the  region  of  the  anus, 
vagina,  and  glans  penis  when  these  parts  are  irritated  by  foul 
discharges,  especially  those  of  gonorrhoeal  origin.  A  curious 
feature  of  multiple  warts  is  that  they  sometimes  appear  on  the 
hands  or  scalp  almost  suddenly,  and  after  persisting  many 
weeks,  or  perhaps  months,  disappear  as  if  by  magic.  When 
warts  are  thickly  crowded  upon  a  limited  area  of  skin — such, 
for  example,  as  the  glans  penis — they  are  apt  to  be  mistaken 
for  more   serious   disease,  such  as  warty  epithelioma. 

Skin  warts  are  overgrown  papillse,  and,  in  sections,  the 
epithelium  will  be  found  to  pass  from  one  papilla  to  another 
in  an  unbroken  line  without  invading  the  fibrous  framework. 

A  solitary  wart  may  occur  on  any  skin-covered  surface 
and  persist.  A  wart  of  this  character  sometimes  attains  the 
size  of  a  walnut,  and  in  some  cases  is  mottled  with  black 
pigment.  Such  warts,  late  in  life,  may  become  the  starting- 
points  of  melanomata. 

A  wart  occasionally  grows  rapidly,  and  may  even  attain  the 
size  of  the  closed  fist,  and  look  very  formidable.  An  admirable 
example  has  been  recorded  by  McCarthy.  A  man  seventy- 
six  years  of  age  came  under  his  care  with  a  tumour  of  the 


PAPILLOMATA. 


169 


size  of  half  an  orange  completely  concealing  the  right  eye. 
This  tumour  was  very  vascular,  bled  freely  on  the  slightest 
manipulation,  and  though  appearing  to  spring  from  the  orbit, 
really  grew  from  the  right  cheek  immediately  below  the  ej^elid. 


.   '#^ 


Pig.  84. — Wart  growing  from  the  skin  of  the  cheek  and  obscui-ing  the  eye.    (After  McCarthy.) 


The  patient  had  had  a  small  wart  on  the  cheek ;  this  grew 
to  the  size  of  a  walnut,  and  was  then  removed  with  a  cautery. 
It  quickly  returned,  and  attained  the  size  represented  in  Fig.  84 
in  about  thirteen  months.  It  was  removed  and  examined 
microscopically  by  McCarthy.  The  cut  surface  of  the  tumour 
was  dotted  with  numerous  yellow  circular  dots  of  the  size  of  a 
pin's  head.  Magnified  sections  showed  the  tumour  to  consist  of 
large  branching  columns  of  epithelial  cells;  the  cells  were 
large,  with  oval  nuclei,  and  the  centre  of  some  of  the  columns 
was  occupied  with  necrotic  tissue.     The  plan  of  structure  of 


170  EPITHELTAL    TUMOURS. 

this  tumour  is  shoAvn  in  Fig.  85,  and  McCarthy  points  out  that  it 
is  identical  with  the  variety  of  tumour  originating  in  soft  warts 
of  the  face  to  which  Billroth*  applies  the  term  plexiform  sar- 
coma. McCarthy  points  out  that  this  is  inconsistent  with  the 
structure  of  sarcomata,  for  these  plexiform  cord-like  bands  are 
composed  of  epithelial  cells. 

I  have  had  an  opportunity  of  studying  a  tumour  in  every 
way  similar  to  the  case  just  mentioned,  only  the  growth  was 
seated  among  the  pubic  hairs  of  a  man  thirty-six  years  of  age. 


Cf^®i§^ 


^^^^jjM 


Fig.  So. — Microscopical  characters  of  the  wart  in  the  preceding  figure. 

(Plate  IV.)  The  tumour  originated  in  a  wart,  was  as  large  as 
a  closed  fist,  as  pink  as  a  cock's  comb,  smeared  with  purulent 
fluid,  and  exhaled  an  abominable  odour.  The  glands  in  each 
groin  were  enlarged.  The  tumour  was  freely  removed,  and  as 
the  wound  cicatrised  the  inguinal  glands  dwindled  to  their 
natural  size.  This  was  sufiicient  evidence  that  the  growth  was 
not  malignant. 

Histologically  the  tumour  was  identical  with  that  so  well  de- 
scribed by  McCarthy,!  and  I  have  no  difliculty  in  accepting  his 
reiterated  opinion  that  the  plexiform  cord-like  bands  are  com- 
posed of  epithelial  cells,  and  the  growths  are  very  large  warts. 

*  "  Surgical  Pathology,"  ed.  8,  p.  414,  vol.  ii 

t  Trans.  Path.  Soc,  vols,  xxxi.,  p.  256;  xxxiii.  (Sup.  Rep.),  and  xliii.,  p.  161. 


leliii 


PLATE  IV. 


-An   unusual  form  of  Wart,  growing  from  the  Skin  of 
the  Pubes.     {Trans.  Path.  Soc,  vol.  xliii.,  1(J"J.) 


FAPILLOMATA.  171 

In  sections  prepared  from  my  specimen  the  epithelial 
cylinders  were  so  large  as  to  be  visible  to  the  naked  eye.  A 
second  case  was  brought  under  my  notice  by  Dr.  Saville  in  a 
woman  nearly  forty  years  of  age ;  in  this  instance  the  wart  grew 
from  the  skin  of  the  left  temple.  In  this  specimen  it  could 
easily  be  shown  that  the  epithelial  processes  were  exaggerated 
papillse  of  the  skin. 

The  difficulty  of  demonstrating  the  continuity  of  the 
epithelial  columns  with  the  papillfe  of  the  adjacent  skin,  is 
due  to  the  circumstance  that  the  surfaces  of  the  warts,  in  the 
cases  depicted  in  Fig.  84  and  Plate  lY.  were  destroyed  by 
ulceration. 

Cutaneous  warts  are  by  no  means  unconmion  in  domesti- 
cated animals.  They  are  frequent  on  the  penes  of  horses  and 
bulls,  the  lips  of  lambs,  and  the  pads  on  the  feet  of  dogs  and 
other  species  of  carnivora. 

Warts  similar  in  structure  to  those  of  the  skin  occur  on 
mucous  membranes  with  a  covering  of  squamous  epithelium, 
such  as  the  lips,  buccal  aspect  of  the  cheeks,  vestibule  of  the 
nose,  and  the  larynx.  The  oesophagus  of  the  ox  is  occasionally 
the  seat  of  a  multitude  of  dendritic  warts. 

Warts  on  mucous  membranes  are  not  so  common  as  on 
cutaneous  surfaces,  but  they  are  apt  to  give  rise  to  much 
more  serious  consequences,  especially  when  springing  from 
the  interior  of  the  larynx. 

Laryngeal  Warts. — In  the  larynx  warts  most  commonly 
spring  from  the  mucous  membrane  covering  the  true  cords : 
frequently  they  grow  immediately  beneath  the  cords,  and  a 
not  uncommon  situation  is  immediately  beneath  the  point  of 
attachment  of  the  vocal  cords  to  the  thyroid  cartilage.  Ex- 
ceptionally a  large  mulberry -like  wart  has  been  detected 
growing  from  the  floor  of  the  sinus  pyriformis.  In  number 
laryngeal  warts  vary  greatly.  Often  one  is  present :  in  other 
cases  ten  or  more  will  be  found.  In  size  there  are  great 
differences ;  some  will  be  no  larger  than  the  head  of  a  pin ; 
they  rarely  exceed  the  dimensions  of  a  small  cherry,  and 
as  a  rule,  they  are  no  bigger  than  split  peas.  The  warts  may 
be  sessile  or  pedunculated ;  in  the  latter  case  they  some- 
times possess  great  mobility,  and  occasionally  get  nipped 
between   the  vocal  cords  and  give  rise    to  urgent  dyspnoea, 


172 


E/'ITIIELIAL    TUMO  URH. 


which  sometimes  ends  in  suffocation.  In  colour  they  are 
of  a  dehcate  pink,  sometimes  of  a  whitish  tint  resembHng 
the  colour  of  the  healthy  cords.  Haemorrhage  into  their 
substance  causes  them  to  assume  a  deep  red  tint. 

Laryngeal  warts  occur  in  children  and  in  adults.  A 
curious  feature  connected  with  them  in  children  is  their 
disappearance  after  tracheotomy.  This  is  somewhat  similar 
to  the  sudden  way  in  which  cutaneous  warts  occasionally  vanish. 

Warts  are  covered  with  squamous  epithelium,  and  the 
cells  are  liable  to  become  transformed  into  horny  material 


Fig.  86. — Wart-lioru  growing  on  tlie  pinna 


and  form  a  cutaneous  horn  (Fig.  86).  Some  of  these  horns 
have  attained  almost  fabulous  sizes. 

As  cutaneous  horns  arise  from  other  abnormal  conditions, 
it  is  usual  to  describe  those  arising  from  warts  as  wart-horns, 
and  it  will  be  convenient  to  defer  their  consideration  to  a 
separate  chapter  dealing  with  horns  in  general. 

2.  Villous  Papillomata. — These  grow  from  the  mucous 
membrane  of  the  bladder,  and  occasionally  in  the  renal  pelvis ; 
the  condition  is  usually  termed  "  villous  disease."  The 
general  appearance  of  the  long,  branching,  feathery  tufts  recalls 
in  a  striking  manner  the  delicate  chorionic  villi.  Structurally, 
the  villi  which  surmount  bladder-warts  are  identical  with 
the  chorionic  villi  in  that  they  consist  of  a  connective-tissue 
core  traversed  by  delicate  blood-vessels,  the  whole  being 
surmounted  by  epithelium. 


FAPILLOMATA. 


173 


These  villous  growths  sometimes  have  broad  bases,  but  in 
other  cases  the  points  of  attachment  are  so  narrow  that  the 
tumours  may  be  described  as  pedunculated.  Usually  villous 
tumours  of  the  bladder  occur  singly,  but  two,  three,  or  more 
may  be  found  in  the  same  bladder.  Occasionally  there  is  one 
fairly  large  growth  and  several  smaller  masses  of  the  size  of 
peas.     In  some  instances  they  occur  at  or  near  the  orifice  of 


Fio;.  87. — Villous  tumour  of  the  bladder. 


the  ureter,  and  though  small,  the  tumour  will  give  rise  to 
serious  changes  in  the  corresponding  kidney  by  obstructing 
the  flow  of  urine  from  the  ureter.  When  the  growth  is 
situated  near  the  neck  of  the  bladder  the  long  villous  tufts 
will  sometimes  be  carried  by  an  outflowing  current  of  urine 
into  the  urethral  orifice  and  cause  impediment  to  its  free 
escape.  (Fig-  87.)  The  delicate  character  of  the  villi  and 
their  vascularity  are  sources  of  danger  because  the  processes 
themselves  are  sometimes  torn,  and  the  haemorrhage  is 
occasionally  so  severe  as  to  place  the  life  of  the  individual 
in  peril. 

Villous  growths,  in  every  way  identical  with  those  found 
in  the  bladder,  are  sometimes  found  growing  from  the  pelvis 


174 


EPITHELIAL    TUMOURS. 


of  the  kidney.  In  one  very  striking  ease  of  this  sort  recorded 
by  Dr.  Mnrchison*  the  pelves  of  the  kidneys  of  a  man  sixty- 
live  years  of  age  were  found  thus  occupied  (Fig.  88),  and  a 
singular  feature  of  the  case  was  the  presence  of  two  villous 
tumours  in  the  bladder,  one  at  the  oritiee  of  each  ureter.  It 
is  not  improbable,  from  what  we  knoAv  of  the  habits  of  warts 


Fig.  S8. — Pelvis  of  a  kidney  with  a  villous  papilloma.     (Museum,  Middlesex  Hospital.) 


generally,  that  in  this  exceptional  mstance  the  vesical  warts 
were  due  to  transplantations  of  epithelium  from  the  pelvis  of 
the  kidney  to  the  mucous  membrane  of  the  bladder. 

It  must  be  remembered  that  the  surface  of  a  vesical 
tumour  is  often  very  ragged,  but  care  must  be  taken  not  to 
confound  a  villous  papilloma  of  the  bladder  with  an  ulcerating 
malignant  vesical  tumour.  There  is  reason  to  believe  that  this 
happens  in  practice. 

*  Trans.  Path.  Soc,  vol.  xxi.  241. 


PAPILL  OMA  TA .  175 

Villous  tuinoiirs  of  the  renal  pelvis  appear  to  be  very  rare 
judging  from  the  paucity  of  recorded  cases. 

There  is  an  interesting  variety  of  villous  papilloma  which 
arises  from  the  choroid  plexuses  of  the  cerebral  ventricles. 
These  plexuses  are  fringed  with  tufts  of  epithelial-coA'ered 
villi  which  occasionally  grow  luxuriantly  and  attain  a  size 
sufficient  to  give  rise  to  unpleasant  effects,  particularly  when 
the  choroid  plexus  of  the  fourth  ventricle  behaves  in  this 
manner.  J.  H.  Douty*  described  a  case  of  "  villous  tumour  of 
the  fourth  ventricle  "  in  which  the  tumour  was  as  large  as  a 
bantam's  egg ;  it  obstructed  the  interventricular  communica- 
tions and  led  to  distension  of  the  lateral  and  third  ventricles  ; 
the  aqueduct  of  Sylvius  was  dilated  to  the  size  of  a  quill. 
The  patient  was  a  boy  seventeen  years  old,  and  the  clinical 
features  were  such  as  to  permit  of  accurate  localisation  of  the 
lesion  during  life. 

Dr.  Clifford  Allbuttt  has  recorded  the  facts  relating  to  a 
girl  nine  years  of  age  who  had  a  villous  tumour  sprouting  into 
the  subarachnoid  space  from  the  left  side  of  the  medulla. 
The  description  of  the  case  is  sufficient  to  show  that  it  arose 
from  the  choroid  plexus  of  the  left  cornucopia.  The  situation 
of  the  tumour  was  accurately  localised  during  life. 

Villous  tumours  of  the  ventricles  rarely  attain  such  a  size 
without  undergoing  calcihcation  and  becoming  transformed 
into  psammomata,  a  species  of  tumoiu-  that  will  be  more 
conveniently  dealt  with  in  a  sejDarate  chapter. 

3.  Intracystic  villous  papillomata  sometimes  arise  in 
mammar}^  cysts.  The  specimen  depicted  in  Fig.  89  is  a  good 
example.  The  cyst  itself  is  formed  by  the  dilatation  of  a 
galactophorous  duct  and  is  lined  with  cubical  epithelium : 
from  one  side  of  the  cyst  a  villous  papilloma  has  grown,  and 
the  processes  completely  till  and  distend  its  cavity.  The  pro- 
cesses have  exactly  the  same  structure  as  the  villi  in  vesical 
papillomata.  In  this  form  of  intracystic  papilloma  the 
analogy  to  the  vesical  tumour  is  further  borne  out  by  their 
liability  to  haemorrhage,  an  abundant  discharge  of  blood-stained 
fluid  from  the  nipple  being  a  fairly  constant  clinical  feature. 


*  £raiii,  vol.  viii.  409. 

t  Trans.  Path.  8oc.,  vol.  six.  20. 


176 


EPITHELIAL    TUMOURS. 


Pollard*  has  described  and  figured  a  good  case  of  villous 
papilloma  in  a  cyst  which,  probably  arose  in  an  accessory 
thyroid  gland. 


RETRAC- 
NIPPLC 


Fig.  89.— Section  of  a  mamma  with  a  dilated  duct  filled  with  villous  jiapillomata. 
(From  a  woman  sixty-eight  years  of  age.f) 


The  description  of  cysts  with  luxuriant  papillomata  which 
sometimes  arise  in  the  paroophoron  should  be  read  in  con 
nection  with  this  chapter. 

*  Trans.  Path.  Soc,  vol.  xxxvii.  507. 
t  Trans.  Path.  Soc,  vol.  xliii.  117. 


177 


CHAPTER    XIX. 

PAPILLOMATA  (conclucled). 

4.  Psammomata. — These  are  tumours  composed  of  globular 
bodies  consisting  of  epithelial  cells  arranged  in  layers,  usually 
calcified,  and  embedded  in  connective  tissue ;  they  are  con- 
fined exclusively  to  the  pia  mater  of  the  brain  and  spinal 
cord.  In  the  case  of  the  brain  the  epithelium  is  derived 
from  the  villous  processes  of  the  choroid  plexuses  of  the 
ventricles ;  hence  psammomata  are  most  frequently  found  in 
connection  with  the  velum  interpositum,  the  roof  of  the  fourth 


Fig.  90. — Microscopical  appearance  of  a  typical  psanimoma. 

ventricle,  and  those  prolongations  of  its  choroid  plexus  which 
occupy  the  lateral  recesses  and  come  into  relation  with  each 
cornucopia. 

The  amount  of  calcareous  material  in  a  psammoma  is 
sometimes  so  abundant  that  it  feels  like  stone.  This  earthy 
matter,  not  only  in  composition,  but  also  in  its  relation  to  the 
tissue  of  the  tumour,  is  identical  with  that  in  the  pineal 
body. 

The  concentric  bodies  are  intimately  associated  with  the 
blood-vessels  of  the  tumour.  A  psammoma  rarely  exceeds  in 
size  a  shelled  walnut,  whilst  specimens  no  bigger  than  peas  are 

M 


178 


El'ITIIELIAL   TUMOlfliS. 


very  common  on  the  choroid,  plexuses  of  the  lateral  ventricles, 
and  in  this  situation  they  are  often  bilateral ;  in  the  third  ven- 
tricle a  psammoma  is  nearly  always  single,  and  this  is  the  case 
with  the  fourth  ventricle,  except  when  springing  from  those 
portions  of  the  plexus  which  lie  in  the  lateral  recesses ;  they 
are  then  apt  to  be  bilateral. 

When  psammomata  occupy  the  lateral  ventricles  they  will 
often  attain   a  fair   size   without    giving   rise   to  symptoms, 


Fig.  91. — Bilateral  psammomata  in  relation  witli  the  lateral  recesses  of  the  fourth  ventricle. 

(After  Strahan. ) 

although  they  produce  in  some  instances  deep  bays  in  the 
substance  of  the  optic  thalami.*  The  situation  of  the  tumour 
materially  influences  its  effects  upon  the  cerebral  functions. 
Beevorf  has  described  a  case  in  which  a  psammoma  7  "5  cm.  by 
6  cm.  grew  from  the  membranes  over  the  median  lobe  of  the 
cerebellum  in  a  lad,  and  caused  headache,  vomiting,  blindness, 
optic  neuritis,  priapism,  opisthotonos,  and  other  disturbances, 
ending  in  death. 

The  most  interesting  examples  arise  from  the  villi  of  the 
choroid  plexus  in  relation  with  the  cornucopia,  and  are  often 
bilateral.  A  typical  specimen  is  represented  in  Fig.  91  from  a 
man  twenty-eight  years  of  age  ;  he  was  violent,  suicidal,  blind, 

*  Eve,  Trans.  Path.  Soc,  vol.  xxxiii.  14. 
t  Srain,  July,  1881. 


fapillomata:  179 

and  deaf.  In  this  situation  the  tumours  came  into  relation 
with  the  seventh,  eighth,  ninth,  and  tenth  cranial  nerves  as 
they  issued  from  the  bulb,  and  with  the  flocculus.  The  clinical 
history  of  the  case  is  given  very  carefully  by  Strahan.* 

It  is  easy  to  understand  that  tumours  growing  in  such 
close  relation  with  important  nerves  as  the  trigeminal,  facial, 
vagus,  etc.,  would  soon  lead  to  symptoms  and  surely  attract 
attention,  and  as  a  matter  of  fact,  a  large  number  of  examples 
have  been  recorded  under  a  variety  of  names,  such  as  sarco- 
matous tumours  of  the  fifth  and  seventh  nerves ;  fibro-sarco- 
matous  tumours  of  the  flocculus ;  symmetrical  tumours  of  the 
medulla,  and  the  like.  Although  fibrous  tumours  (neuromata) 
undoubtedly  grow  from  the  intracranial  portions  of  the  fifth, 
seventh,  and  other  nerves  arising  from  the  medulla  oblongata, 
yet  the  majority  of  tumours  found  in  the  immediate  vicinity 
of  the  flocculus  are  psammomata  connected  with  the  villi  of 
the  choroid  plexuses  of  the  fourth  ventricle. 

In  the  memorable  exhibition  of  cerebral  tumours  that 
took  place  at  the  Pathological  Society,  London,  in  1886,  some 
good  specimens  of  psammomata  in  the  floccular  region  were 
exhibited  by  Drs.  Goodhart,  F.  Taylor,  and  Beevor.  In  most 
of  the  cases  there  was  headache,  vomiting,  and  deafness ;  in 
several  difiiculty  of  swallowing  and,  when  the  tumour  was 
large,  unsteady  gait,  probably  due  to  pressure  upon  the 
cerebral  peduncles. 

It  is  somewhat  curious  that  of  some  score  or  more  of  these 
cases  which  are  recorded,  and  which  were  observed  very  care- 
fully, none  of  the  observers  recognised  the  fact  that  the 
tumours  were  identical  with  psammomata  of  the  lateral 
ventricles. 

Psammomata  are  fairly  common  growing  from  the  choroid 
plexuses  of  the  lateral  ventricles  of  horses.  In  this  situation 
they  may  attain  the  size  of  a  walnut  and  not  obviously  disturb 
the  function  of  the  organ.  When  they  attain  a  larger  size  one 
tumour  usually  outstrips  the  other,  as  in  Fig.  92 ;  and  I  have 
seen  two  of  these  tumours  in  the  lateral  ventricles,  one  being 
as  large  as  a  hen's  egg  and  the  other  equal  to  that  of  a  ban- 
tam. Such  large  growths  produce  grave  and  even  fi^irious 
symptoms.    The  pressure  effects  alone  wiD.  kill  the  horse  ;  but 

*  Journal  of  Mental  Science,  vol.  xxix.  246. 


180  EPITHELIAL    TUMOURS. 

in  some  of  the  reported  cases  the  animals  have  destroyed 
themselves  by  wild  plunges  made  during  attacks  of  delirium. 

Psammomata  in  horses  are  very  vascular;  some  of  the 
tumours  are  soft  and  contain  little  grit,  whilst  others  are  quite 
hard.     Similar  variations  in  the  consistence  of  these  tumours 

Psamuiomatd. 


Fig.  92. — Psammomata  in  the  lateral  ventricle  of  a  licirse's  brain. 

occur  in  the  human  subject,  but  the  psammoma  of  the  horse 
differs  from  that  of  man  in  the  fact  that  large  quantities  of 
cholesterine  are  present.  Thus  in  a  tumour  found  in  the  right 
lateral  ventricle  of  an  old  horse,  Lassaigne  reported  that  it  was 
composed  of  58  parts  of  cholesterine,  39 "5  membrane  and  albu- 
minous matter,  2 '5  sub-phosphate  of  lime.  Every  writer  on 
these  bodies  in  the  cerebral  ventricles  of  the  horse  refers  to  the 


FAPILLOMATA. 


181 


large  amount  of  cliolesterine  they  contain.*  In  man,  the 
sabulous  material  of  psammomata  consists  of  phosphate  and 
carbonate  of  lime,  with  a  little  phosphate  of  magnesia  and 
ammonia. 

A  careful  study  of  these  tumours  would  lead  us  to  use  the 
term  psammoma  for  tumours  having  the  structure  of  the 
choroid  plexuses,  whether  they  were  soft  or  calcified.  As  a 
typical  example  of  a  soft  or  uncalcified  psammoma  reference 


Pia  matei 


Dura  matei    — f 


Spinal  cord 


Fig.  93. — Portioa  of  the  spinal  cord  with  a  psammoma.    {Museum,  Middlesex  Hospital.) 

may  be  made  to  Ashby's  case,t  in  which  a  boy  three  and  a  half 
years  of  age  died  with  all  the  symptoms  of  cerebral  tumour. 
The  left  lateral  ventricle  was  occupied  by  a  soft  lobulated  vas- 
cular mass  which  had  apparently  commenced  in  the  choroid 
plexus,  and  consisted  of  capillary  vessels  distended  with  blood, 
with  epithelial  cells  arranged  around  them. 

Psammomata  of  the  Spinal  Membranes  lead  to  far  more 
serious  results  than  tumours  of  a  similar  size  in  the  lateral 
ventricles,  and  are  almost  as  dangerous  when  seated  high  in 

*  Gamgee,  Veterinarian,  1852. 

t  Trans.  Patli.  Soc,  vol.  xxxvii.,  p.  56. 


182  EPITHELIAL   TUMOURS. 

the  spinal  canal  as  psammoinata  near  the  flocculus.  In  the 
spinal  canal  these  tumours  do  not  attain  a  large  size — indeed 
in  the  feAv  recorded  cases  there  is  singular  nniforinity  in  their 
shape  and  dimensions. 

A  typical  example  of  a  psammoma  of  the  spinal  membranes 
is  sketched  in  Fig.  93.  The  specimen  now  preserved  in  the 
museum  of  the  Middlesex  Hospital  was  described  in  1865  by 
Dr.  Cayley.*  The  tumour  was  situated  on  the  left  side  of  the 
cord,  at  a  spot  corresponding  to  the  interval  between  the  tenth 
and  eleventh  thoracic  vertebrse.  It  was  of  oval  shape,  and 
measured  3  cm.  in  its  lono-  and  1"5  cm.  in  its  short  axis:  its 
surface  was  smooth,  and  aj)peared  to  be  invested  by  the  arach- 
noid. The  cord  was  much  compressed  and  softened  by  the 
tumour.  The  patient,  a  woman  forty-six  years  of  age,  died 
paraplegic.  The  history  of  aU  such  cases  has  been  slow  pro- 
gressive paralysis  and  death.  In  the  future,  such  cases  will  be 
submitted  to  surgical  measures. 

*  Trans.  Path.  Soc,  vol.  xvi.,  i3.  21  ;  for  similar  cases  .sw  AVhipham,  Hid.,  \ol. 
xxiv.  15 ;  Hutchinson,  ibid.,  xxxiii.  23 ;  and  Lediard,  ihid.,  xxxiii.  25. 

Note. — Miiller  described  under  the  name  cholesteatoma  certain  tumours 
composed  of  layers  of  epithelium  mixed  with  cholesterine,  or  calcareous  matter ; 
it  prohahly  included  a  certain  variety  of  sebaceous  cyst,  psammomata,  epithelial 
pearls,  and  the  "  nests  "  of  epithelioma.  In  recent  years  the  term  has  been  used 
even  more  vaguely,  so  that  it  becomes  urgently  necessary  to  drop  it. 


183 


CHAPTER  XX. 

CUTANEOUS  HORNS. 

Cutaneous     Horns    in    the    liuman    subject     are    of    four 
varieties  : — 

1.  Sebaceous  horns. 

2.  Wart  horns. 

3.  Cicatricial  horns. 

4.  Nail  horns. 

■  1.  Sebaceous  Horns  are  very  common,  and.  arise  in  situa- 
tions  where   sebaceous   glands   exist.     They   are   formed   in 


Fig.  04. — Cutaneous  horn  :  tlie  widow  Dimanehe. 

consequence  of  the  protrusion  of  the  contents  of  a  sebaceous 
cyst  through  a  rupture  in  the  cyst  wall,  or  through  the  duct  of 
the  follicle,  which  becomes  desiccated  on  exposure  to  the  air  ; 
fresh  material  is  added  to  the  base  of  the  horn,  until  at  last  a 
horn  may  be  produced  measuring  in  some  instances  15  cm. 

One  of  the  most  remarkable  cases  is  that  of  the  widow 
Dimanehe.      She   was  a  "  dame  aux   halles."     A  long  horn 


184 


EPITHELIAL   TUMOURS. 


grew  from  the  forehead,  as  represented  in  Fig.  94,  and  a 
smaller  one  from  the  right  cheek.  A  wax  cast  of  this  woman's 
face   is  preserved  in  the   museum  of  the  Royal  College  of 


Surgeons,  England. 


Sebaceous  horns  are  extremely  tough,  and  present  a  longi- 
tudinal fibrillation  ;  when  soaked  in  a  weak  solution  of  liquor 


Fig.  95. — Cutaneous  horn  from  the  penis.     (After  Pick.*) 


potassse  they  quickly  soften  and  the  horny  material  comes 
away  in  flakes. 

2.  A  Wart  Horn  is  structurally  identical  with  the  seba- 
ceous horn,  and  it  is  impossible  to  decide  from  an  examina- 
tion of  a  large  horn  whether  it  grew  from  a  sebaceous  cyst 
or  from  a  wart.  Sebaceous  horns  are  more  frequent  on  the 
scalp  than  elsewhere,  whilst  wart  horns  are  most  frequently 
found  on  the  penis  (Fig.  95),  and  are  not  rare  on  the  pinna. 
It  is  important  to  bear  in  mind  that  epithelioma  is  apt  to 

*  Arch,  fiir  Dermat.  und  Syph.,  1875,  s.  315. 


H0BN8. 


185 


originate   in    the    skin    around   the    bases    of  wart    horns, 
especially  in  elderly  patients. 

The  only  means  of  deciding  between  a  wart  horn  and  a 
sebaceous  horn  is  by  dividing  them  longitudinally,  and  ascer- 
taining the  existence  or  otherwise  of  a  cyst  at  the  base  of  the 
horns.  In  the  case  of  the  mouse  sketched  in  Fig.  96,  some 
pathologists  who  examined  it  were  of  opinion  that  it  was  a 
wart    horn,   but   on   dissection   a   large   sebaceous   cyst   was 


Fif^.  96. — Sebaceous  horn  in  a  mouse. 


found  to  occupy  its  base.  Horns  of  this  character  are  not 
rare  in  mice. 

The  most  elaborate  collection  of  cases  illustrating  cutaneous 
horns  is  contained  in  a  small  work  published  by  Dr.  Herman 
Lebert.*  He  gives  accounts  of  one  hundred  and  nine  cases 
with  references,  the  earliest  dating  from  the  year  1300.  The 
horns  were  found  on  the  scalp,  temple,  forehead,  eyelid, 
nose,  lip,  cheek,  shoulder,  arm,  elbow,  thigh,  leg,  knee,  toe, 
axilla,  thorax,  buttock,  loin,  penis,  and  scrotum.  In  length 
they  varied  from  1  to  20  cm.  Lebert,  however,  makes  no 
attempt  to  discriminate  between  the  variety  of  horns. 

The  most  curious  situation  in  which  cutaneous  horns 
occur  is  in  ovarian  dermoids  growing  from  sebaceous  cysts  in 
the  skin  lining  the  cavities  of  these  tumours.  The  conversion 
of  epithelium  into  horn  in  cases  of  sebaceous  cysts  and  warts 

*  "  Ueber  Keratose,"  Breslau,  1864. 


186  EPITHELIAL    TUMOURS. 

is  soiiietliing  more  than  desiccation  from  exposure ;  it  is 
doubtless  akin  to  the  change  by  which  nail  and  horn  are 
formed  under  normal  conditions. 

A  good  physiological  type  of  a  wart  horn  is  presented  by 
the  nasal  horn  of  the  rhinoceros,  for  this  formidable  cutaneous 
appendage  is  nothing  more  than  a  gigantic  wart.  Professor 
Flower  exhibited  at  the  Zoological  Society,*  London,  a  portion 
of  the  skin  from  the  head  of  a  rhinoceros  (shot  by  Sir  John 


Fig.  97. — Head  of  an  African  rhinoceros  with  a  large  wart  posterior  to  and  in  a  line 
with  its  nasal  horns. 

C.  Willoughbyt  in  Central  Africa)  furnished  with  three  horns. 
The  accessory  horn  is  structurally  a  wart  ;  it  was  12  cm. 
high,  and  42  cm.  in  circumference.     (Fig.  97.) 

A  physiological  type  of  sebaceous  horns  is  furnished  by 
the  curious  patch  of  spines  on  the  forearm  of  Hapalemur 
{Hwpalemur  griseus).  It  is  present  only  in  the  adult  male. 
The  spines  are  identical  in  .  structure  with  sebaceous  horns, 
and  are  formed  of  hardened  secretion  furnished  by  a  multitude 
of  glands  in  the  skin  immediately  underlying  the  patch  of 
spines.  The  male  Ring-tailed  Lemur  (Lemur  catta)  has  a 
curious  horn-like  spur  upon  its  forearm  near  the  wrist,  also 
associated  with  a  collection  of  glands.  J 

Cutaneous  horns  are  sometimes  found  on  cows,  sheep,  and 
goats.     They  may  attain  a  large  size.     The  museum  of  the 

*  Proc.  Zool.  Soc,  1889,  p.  448.     f  "  East  Africa  and  its  Big-  Game,"  1889,  p.  155. 
t  Proc.  Zool.  Soc,  1887,  p.  369. 


HORNS. 


187 


Royal  College  of  Surgeons  contains  a  very  large  liorn  that 
grew  from  the  flank  of  a  ram.  This  horn  is  nearly  a  metre 
in  length,  and  in  its  dried  condition  is  28  cm.  in  circnm- 
ference  at  the  base.     This  specimen  is  described  with  others 


Fig.  98.— Head  and  leg  of  a  tlirusli  with  cutaneous  horns.     The  horns  were  east  each 
time  tlie  bird  nioulted. 


by  Sir  Everard  Home  in  an  interesting  paper  in  the  Phil. 
Trans.,  1791. 

Birds  are  liable  to  cutaneous  horns ;  the}^  grow  very 
rapidly,  and  sometimes  attain  great  lengths.  It  is  also  a 
curious  fact  that  they  follow  the  rule  with  regard  to  the 
epidermic  structures  in  this  class  generally,  and  are  cast  oft' 
when  the  birds  moult. 

In  the  case  of  the  thrush  whose  head  and  leg  are  sketched 
in  Fig.  98,  the  horn  on  the  head  probably  grew  from  a  sebaceous 
cyst,  and  that  on  the  leg  from  a  wart.  I  have  seen  similar 
horns  in  canaries,  linnets,  blackbirds,  and  in  an  oyster-catcher. 

3.  Horns  growing  in  the  cicatrices  of  burns  are  very  rare. 


188 


EPITHELIAL   TUMOUEH. 


The  best  example  which  has  come  under  my  notice  I  owe  to 
Mr.  P.  Benthf  of  Jersey.  The  patient,  a  woman  forty-nine 
years  of  age,  was  severely  burnt  when  a  child  over  the  lower 
part  of  the  trunk  and  thigh.  At  the  age  of  forty-two  years 
a  portion  of  the  scar  on  the  thigh  ulcerated  and  slowly  healed  ; 
as  it  healed  it  became  scaly,  and  in  the  course  of  the  succeed- 
ing six  years  the  superimposed  scales  formed  the  large  flat- 
topped  horn  represented  in  Fig.  99.  This  horn  is  5  cm.  square 
at  the  base  and  nearly  3  cm.  high,  and  the  material  of  which 
it  is  formed  is  regularly  stratified  like  a  pie-crust. 


Fig.  99. — Horn  formed  on  the  cicatrix  of  a  burn.     {Musexim,  Middlesex  Hospital.) 

After  the  horn  had  been  growing  steadily  for  six  years  it 
loosened  and  fell  off  in  the  night,  leaving  an  ulcerated  surface. 
As  the  ulcer  healed  a  new  horn  began  to  form. 

The  most  remarkable  horn  originating  in  this  way  is  de- 
scribed by  Cruveilhier.*  The  specimen  formed  part  of 
Beclard's  collection,  and  is  sketched  in  Fig.  100.  On  the  palmar 
aspect  of  the  hand  there  is  a  horny  mass,  with  numerous  pro- 
jections, varying  in  length  from  2  to  20  cm. ;  the  corneous 
material  is  disposed  in  some  parts  in  laminae,  but  in  others  has 
a  longitudinal  disposition.  In  the  absence  of  a  history, 
Cruveilhier  could  only  conjecture  as  to  the  cause  of  this 
astonishing  production,  but  he  describes  some  similarly-shaped 
horns  that  came  under  his  notice  in  the  thighs  of  old  women 
at  the  Salpetriere ;  the  horns  grew  from  the  scars  of  old  burns 
When  they  became  detached  they  left  painful  ulcers. 

*  Anat.  Path.,  pi.  vi.,  Livraison,  vii. 


HORNS. 


189 


Mr.  Edmunds*  exhibited  to  the  Pathological  Society, 
London,  a  horn,  very  similar  to  Cruveilhier's  specimen,  which 
originated  in  the  scar  of  a  burn  on  the  hand  sustained  sixty- 


Fig.  100.— Horns  growing  from  the  scar  of  a  burn.    (After  CruveilMer.) 

five  years  previously.  After  the  horn  had  been  growing  three 
years  it  began  to  slough,  and  in  the  course  of  the  next  two 
years  became  so  offensive  as  to  necessitate  amputation. 

4.  Nail  Horns  do  not  call  for  much  consideration.  They  are 
extremely  common  on  the  toes  of  bedridden  patients,  especially 
old  women  and  those  who  are  dirty.   Although  nail  horns  may 

*  Trans.  Path.  Soc,  vol.  xxxviii.,  p.  352. 


190  EFITHEIJAL    TUMOURS. 

grow  on  any  of  the  toes,  they  are  most  fre(|iiently  met  with  on 
the  big  toe.  The  horns  may  attain  a  length  of  7  cm.,  and 
become  twisted  so  as  to  resemble  ram's  horns. 

Treatment. — Cutaneous  horns  are  easily  detached  Ijy  a 
sudden  jerk  Avith  the  thumb  and  forefinger;  if  they  are  too 
firmly  fixed  to  be  removed  in  this  way,  then  they  may  be 
excised.  An  exceptional  case,  such  as  that  depicted  in  Fig. 
100,  will  demand  amputation,  and  in  a  few  instances  surgeons 
have  thought  it  necessar}'-  to  remove  the  extremity  of  the 
penis  when  the  skin  surrounding  the  base  of  the  horn  has 
been  ulcerated.  When  epithelioma  attacks  the  skin  at  the 
base  of  a  horn,  it  should,  with  the  surrounding  skin,  be  early 
excised. 


191 


CHAPTER    XXI. 

EPITHELIOMA. 


Ax  epithelioma  may  arise  on  any  part  of  the  body  where  strati- 
lied  epithelium  exists,  but  is  more  prone  to  occur  in  situations 
where  there  is  a'  transition  from  one  kind  of  epithelium  to 


Fig.  101. — Epithelioma  of  the  upper  lip  (early  stage). 

another,  and  especially  at  spots  where  skin  and  mucous  mem- 
brane come  into  relation — e.g.  the  lips  and  the  anus. 

Histologically,  an  epithelioma  diifers  from  a  wart  in  the 
fact  that  the  epithelium  is  no  longer  limited  by  the  basement 
membrane,  but  passes  beyond  it  into  the  underlying  connective 
tissue.  This  invasion  is  attended  by  peculiar  cell  formations, 
known  as  epithelial  nests.  The  disease  almost  invariably 
recurs  after  removal,  and  is  exceptionally  liable  to  infect  the 
neighbouring  lymph  glands. 


192 


EPITHELIAL   TUMOURS. 


An  epithelioma  may  make  its  appearance  as  a  wart,  as  a 
fissure,  or  as  a  nodule  on  the  surface  of  skin  or  mucous 
membrane.  Perhaps  the  most  frequent  form  is  that  depicted 
in  Fig.  101,  where  the  epithelioma  has  the  look  of  an  ulcer 
with  raised,  rampart-like  edges ;  the  ulceration  is  due  to  necrosis 
of  the  cells  forming  the  central  parts  of  the  initial  nodule. 


Fig.  102. — Epithelioma  of  the  lip,  beginning  in  a  Assure. 


When  the  disease  starts  in  a  fissure,  and  ulceration  keeps 
pace  with  the  infiltration,  then,  instead  of  raised  edges,  the 
ulcer  has  margins  as  sharply  defined  as  those  of  a  rodent  ulcer ; 
occasionally  the  edges  are  undermined.      (Fig.  102.) 

There  is  a  third  variety,  in  which  processes  project  from  the 
skin  like  warts,  and  their  free  surfaces  are  sometimes  quite 
horny.      (Fig.  103.) 

Although  these  three  clinical  varieties  of  epithelioma  look 
so  different,  they  are  identical  in  structure.  When  sections 
are  cut  in  such  a  way  as  to  include  not  only  the  edge  of  the 
ulcer  but  the  adjoining  tissue  also,  the  surface  epithelium  will 


EPITHELIOMA. 


193 


be  found  to  dip  into  the  underlying  tissue  in  the  form  of  long 
columns.  (Fig.  104.)  The  parts  around  these  cell-columns  are 
infiltrated  with  adventitious  cells ;  among  and  beyond  these 
columns,  as  well  as  within  them,  curious  concentric  cellular 


>^ 


"^^(.IX, 


Fig.  103. — "  Warty"  variety  of  epitlielioma. 


bodies,  known  as  epithelial  nests,  are  met  with.  The  cells  com- 
posing these  nests  are  arranged  around  two  or  more  altered 
cells  like  the  layers  of  an  onion.  The  cell-columns  are  not 
enclosed  by  a  membrane,  and  some  of  the  larger  columns  tend 
to  branch  and  even  fuse  with  adjacent  columns,  forming  a 
network  in  the  deeper  tissues.  It  matters  not  whether  the 
epithelioma  grows  on  the  lip,  the  tongue,  the  larynx,  or  the 
edge  of  a  scar  on  the  leg  or  hand,  this  peculiar  disposition  of 
cell-columns  is  observed  accompanied  by  the  cell-nests      The 


194  EPITHELIAL    TIIMOULS. 

size  of  the  columns  and  the  number  of  the  nests  vary  in 
different  cases,  but  the  plan  of  invasion  is  the  same  in  all  cases. 
It  is  important  to  bear  in  mind  that  the  three  clinical  varie- 
ties of  epithelioma  occur  in  most  of  the  situations  that  are 
liable  to  this  disease ;  in  addition  to  the  lip,  it  has  come  under 
my  notice  in  the  tongue,  anus,  buccal  aspect  of  the  cheek,  glans 


I 


'^ 


Fig.  ] 04.— Microscopic  appearance  of  the  cells  in  epithelioma  ;  the  connective 
tissue  stroma  is  omitted.    (After  Sheridan  DeUyine.) 

penis,  vaginal  surface  of  the  uterine  cervix,  and  at  the  edge  of  old 
scars.  The  non-recognition  of  these  three  manifestations  of 
epithelioma  has  produced  much  confusion  in  surgical  writings. 
For  instance,  the  warty  form  has  in  many  instances  been 
described  as  epithelioma  supervening  on  warts. 

The  primary  ulcers  when  left  to  themselves  may  extend 
and  involve  extensive  tracts  of  tissue,  or  fungate  and  form 
huge  granulating  cauliflower-like  growths.  In  either  case  the 
superficial  parts  are  continually  being  cast  off  in  a  foul,  foetid 
discharge  containing  sloughs  of  tissue,  cellular  detritus,  and 


EPITHELIOMA.  195 

blood.  Any  vascular  tissue,  sucli  as  skin,  nuiscle,  and  mucous 
membrane,  is  quickly  infiltrated  and  destroyed ;  even  bone  is 
rapidly  eroded  and  removed  piecemeal.  Cartilage  resists 
invasion,  and  this  is  seen  in  a  striking  way  in  those  rare 
instances  when  epithelioma  attacks  the  pinna ;  the  skin  and 
soft  tissues  quickly  disappear,  whilst  its  cartilaginous  frame- 
work stands  prominently  out  among  the  surrounding  ruin. 

Epithelioma  in  whatever  situation  it  occurs  usually  destroys 
life  rapidly.  The  quickness  with  which  it  ulcerates  and  over- 
comes all  resistance  enables  it  to  open  up  large  blood-vessels 
should  any  lie  in  its  way.  Hence  death  from  hsemorrhage  is 
frequent;  when  the  tumour  is  near  the  air-passages,  foul 
material  is  inspired  and  initiates  septic  pneumonia. 

Particular  modes  of  death  occur  according  to  the  situation 
of  the  epithelioma,  and  it  will  be  more  convenient  to  refer  to 
these  when  dealing  with  the  disease  in  the  various  situations 
in  which  it  occurs  than  to  attempt  a  summary  of  them 
here. 

The  three  varieties  exhibit  different  degrees  of  malignancy. 
The  burrowing  variety  rapidly  kills,  whilst  the  warty  epithe- 
lioma runs  much  the  slowest  course;  but  each  manifests  its 
malignancy  in  the  same  manner  by  recurring  after  removal, 
by  infecting  acljacent  lymph  glands,  and  occasionally  by 
dissemination. 

Lymph  Gland  Infection. — The  rapidity  with  which  lymph 
glands  are  affected  constitutes  at  the  same  time  the  most  re- 
markable and  dangerous  feature  of  epithelioma ;  the  large  size 
the  infected  glands  attain  in  many  cases  is  often  astonishing, 
and  their  enlargement  stands  in  no  relation  to  the  size  of  the 
initial  lesion,  for  an  epithelioma  2  cm.  square,  or  less,  will  lead 
to  the  formation  of  a  gland  tumour  as  big  as  a  cocoa-nut.  Such 
conditions  are  most  frequently  met  with  when  the  tongue,  lip, 
and  scrotum  are  the  seats  of  epithelioma. 

The  gland  complication  in  epithelioma  is  always  a  serious 
element  of  danger.  When  the  cervical  glands  are  enlarged 
they  interfere  with  the  trachea  and  oesophagus.  They  also 
become  firmly  adherent  to  the  sheaths  of  big  vessels,  and  as 
the  glands  break  down  the  ulceration  not  infrequently  opens  up 
the  jugular  vein  or  carotid  artery,  and,  in  the  inguinal  region, 
the  femoral  vessels.     A  peculiarity  of  glands  infiltrated  by 


196  EPITHELIAL    TTJMOURH. 

epithelioma  is  the  tendency  they  exhibit  to  break  down  in  the 
centre  and  form  spurious  cysts.  This  should  be  remembered, 
for  fluctuating  glands  associated  with  epithelioma  does  not 
necessarily  signify  suppuration.  When  the  skin  becomes 
implicated  large  portions  of  the  infected  glands  slough,  and 
leave  large,  horrible  gaps,  from  which  a  foul  foetid  discharge 
proceeds,  whilst  the  edges  of  the  chasm  produced  by  the  slough- 
ing continue  to  extend  and  involve  the  neighbouring  tissues. 

Dissemination.  —  It  has  already  been  mentioned  that 
secondary  deposits  are  exceptional  in  epithelioma ;  it  cannot 
be  said  that  they  are  rare,  but  dissemination  certainly  happens 
far  less  frequently,  and  never  so  extensively  as  in  cancer. 
It  is  also  noteworthy  that  epithelioma  is  in  some  situations 
more  liable  to  disseminate  than  in  others.  For  example, 
secondary  deposits  are  rarely  met  with  when  this  disease 
attacks  the  larynx,  and  the  mucous  membrane  in  relation 
with  the  mandible  or  maxillas,  and  the  oesophagus.  The 
explanation  sometimes  offered  of  this  peculiarity  is  that 
epithelioma  in  these  situations  usually  runs  a  rapid  course, 
and  often  destroys  life  so  quickly  that  the  period  is  too  short 
to  allow  of  the  formation  of  secondary  nodules.  This  is  in- 
admissible, as  in  epithelioma  of  the  scrotum  dissemination  is 
almost  as  exceptional  as  when  the  larjmx  is  attacked. 

Treatment. — The  principles  on  which  surgeons  rely  for  the 
treatment  of  epithelioma  are  : — 

(1)  Early  and  free  removal  of  the  diseased  part  whenever 

it  is  in  an  accessible  situation. 

(2)  When  adjacent  lymph  glands  are  enlarged  they  should 

be  dissected  out  coincidently  with  the  removal  of  the 
primary  lesion. 

(3)  When  there  is  recurrence,  and  the  condition  of  the 

part  admits,  and  the  general  health  of  the  patient 
is  such  as  will  permit  an  operation  to  be  performed 
with  safety,  the  tumour  should  be  excised. 

The  early  excision  of  epithelioma  is  practised  for  two  ver}^ 
important  reasons  : — 

The  earlier  the  diseased  area  is  removed  the  greater  the 
prospect  of  eradicating  the  disease  before  it  infects  the 
adjacent  lymph  glands. 


EPITHELIOMA.  197 

The  extirpation  of  an  epithelioma  in  its  early  stages  is  oft- 
times  a  very  trivial  proceeding ;  when  allowed  to  extend,  its 
complete  removal  will  often  demand  a  very  extensive,  diffi- 
cult, and  frequently  a  dangerous  operation,  and  often  is  an 
impossible  task. 

It  is  difficult  to  formulate  rules  for  the  operative  treatment 
of  epithelioma  and  to  decide  what  is,  and  what  is  not 
justifiable  surger}^  Every  surgeon  must  be  guided  by  in- 
dividual experience.  It  is  exceedingly  difficult  to  express 
collectively  the  effects  of  operation  in  eradicating  this  disease. 
The  facts  broadly  stated  stand  thus  : — 

In  a  small  proportion  of  cases  the  operation  is  of  doubtful 
utility,  and  in  a  few  instances  life  is  sacrificed  in  consequence 
of  the  interference. 

On  the  other  hand,  a  large  number  of  patients  de- 
rive the  greatest  comfort,  and  their  lives  are  certainl)^ 
prolonged  in  consequence  of  operation. 

In  a  small  number  of  instances  an  actual  cure  is  brought 
about.  When  an  epithelioma  is  removed  and  there  is  no  recur- 
rence for  five  years,  the  individual  may  be  regarded  as  cured. 
The  results  and  relative  dangers  of  operations  for  epithelioma 
will  be  given  in  connection  with  the  various  organs  in  the 
ensuing  pages. 

It  will  be  useful  to  reiterate  here  that  of  the  three  clinical 
varieties  of  epithelioma  the  burrowing  form  is  not  only  the 
most  malignant,  but  gives  the  worst  results  after  operation. 
The  warty  variety  is  not  only  the  least  malignant,  but  affords 
the  best  results  when  excised. 

It  may  be  taken  as  an  axiom  that  in  cases  where  opera- 
tions are  performed  for  ej)ithelioma,  and  as  far  as  could  be 
judged,  the  incisions  were  carried  wide  of  the  diseased  tissues, 
a  quick  recurrence  of  the  disease,  either  in,  or  near,  the  cicatrix, 
or  the  subsequent  enlargement  of  the  lymph  glands,  may  be 
taken  as  an  indication  of  a  high  degree  of  malignancy,  and, 
as  a  rule,  of  the  uselessness  of  further  operative  interference. 

EPITHELIOMA   OF   LIPS,   TONGUE,   MOUTH,   AND   JAWS. 

Epithelioma  of  the  Lips.  —  In  this  situation  it  is  most 
common  between  the  thirty-fifth  and  sixtieth  years ;  it  has 
been  recorded   as   early  as  the  twenty-fifth  year  and  as  late 


198  EriTHELIAJj   TUMOUBH. 

as  102.*  Epithelioma  is  nearly  one  hundred  times  more 
frequent  on  the  lower  lip  of  men  than  women ;  in  men  it  is 
lifty  times  more  common  on  the  lower  than  the  upper  lip. 
When  the  disease  begins  on  the  nether  lip  near  the  angle 
of  the  mouth  it  may  involve  the  upper  lip ;  this  is  rare,  but 
primary  epithelioma  of  the  upper  lip  is  very  rare.  It  is  a 
curious  fact  that  epithelioma  is  more  frequent  on  the  upper 
lip  in  women  than  in  men.  The  mode  in  which  the  disease 
attacks  the  lips  is  shown  in  Figs.  101,  102  and  103. 

Epithelioma  of  the  lip,  when  left  to  run  its  course,  soon 
infects  the  lymph  glands  in  the  submaxillary  region.  Occa- 
sionally epithelioma  will  attack  the  right  side  of  the  lower  lip 
but  infect  the  lymph  glands  in  the  left  submaxillary  region 
and  vice  versa.  No  anatomical  explanation  of  this  anomaly 
is  forthcoming.  The  tissues  of  the  lip  are  gradually  destroj^ed, 
and  the  mucous  membrane  covering  the  mandible  is  impli- 
cated and  the  bone  itself  eroded.  In  the  later  stages  the 
glands  in  the  neck  form  huge  masses,  which  gradually 
implicate  the  overlying  skin,  causing  it  to  ulcerate,  and  at  last 
the  ulcer  in  the  neck  and  the  primary  ulcer  on  the  lip  join, 
and  as  the  underlying  tissues  slough  a  horrible  chasm  is 
formed  in  the  neck,  on  the  floor  of  which  large  vessels  may 
be  seen  pulsating.  Death  is  due  to  asthenia  from  repeated 
haemorrhage,  or  from  a  profuse  haemorrhage,  septic  pneumonia, 
or  oedema  of  the  glottis.  The  average  duration  of  life  in 
untreated  cases  is  twelve  months. 

Treatment. — Epithelioma  of  the  lip  in  the  early  stages  is 
easily  removed  by  the  V-shaped  method,  or  some  one  or  other 
of  its  many  modifications. 

When  the  submaxillary  or  submental  lymph  glands  are 
enlarged  they  should  be  dissected  out.  AVhen  the  disease  has 
been  allowed  to  extend  until  it  involves  the  underlying  bone 
and  extensively  infiltrates  the  cheek  and  neck,  operative 
interference  can  rarely  be  undertaken  with  much  prospect  of 
doing  good. 

After  the  excision  of  an  epithelioma  of  the  lip,  recurrence 
may  take  place  along  the  edge  of  the  scar,  or  in  the  submaxillary 
lymph  glands,  and  as  these  enlarge  the  periglandular  tissue 
also  becomes  infiltrated  with  epitheliomatous  material,  Avhich 

*  Jalland,  Brit.  Med.  Journal,  1891,  vol.  i.,  p.  1019. 


EPITHELIOMA.  199 

renders  the  removal  of  tlie  diseased  tissue  a  difficult  and  often 
impossible  task.  There  is  a  form  of  recurrence  of  epithe- 
lioma of  the  lip  which  begins  near  the  angle  of  the  mandible, 
and  spreads  up  each  side  of  the  body  of  this  bone  in  such  a 
way  as  to  resemble  a  periosteal  sarcoma. 

The  early  removal  of  an  epithelioma  of  the  lip  is  more 
likely  to  be  followed  by  good  results  than  in  any  other  part  of 
the  body.  Occasionally  the  operation  is  followed  by  quick 
recurrence,  even  when  the  primary  lesion  was  very  small ;  but 
in  a  large  proportion  of  cases  recurrence  is  delayed  two,  three, 
or  more  years,  and  in  a  few  cases  a  cure  is  brought  about. 
Operations  for  epithelioma  of  the  lip  should  have  practically 
no  mortality. 

Epithelioma  of  the  Tongue. — In  this  situation  epithehoma 
is  most  frequent  after  the  age  of  forty  years,  but  it  has  been 
recorded  in  patients  as  young  as  twenty-live,  and  in  individuals 
of  seventy-five  years  ;  it  is  three  times  commoner  in  men  than 
women.  This  predilection  of  epithelioma  for  the  tongues  of 
men  is  usually  attributed  to  the  habit  of  smoking. 

Epithelioma  usually  makes  its  appearance  on  one  side  ot 
the  tongue,  usually  near  its  tip ;  in  a  fair  proportion  of  cases 
it  begins  on  the  dorsum,  but  always  distinctly  to  one  side  of  the 
middle  line,  and  the  beginning  of  the  disease  is  a].ways  at 
some  spot  in  the  anterior  tAvo-thirds  of  the  tongue. 

In  a  fair  proportion  of  cases  (twenty  per  cent.)  epithelioma 
of  the  tongue  is  preceded  by  changes  known  as  leukoplakia 
and  ichthyosis :  they  are  frequently  referred  to  as  pre- 
cancerous conditions. 

Ichthyotic  patches  upon  the  tongue  do  not  necessarily 
become  ejDitheliomatous  in  every  individual,  and  when  epithe- 
homa attacks  an  ichthyotic  tongue  it  does  not  always  begin 
in  the  ichthyotic  patch ;  indeed,  epithelioma  is  sometimes 
seen  on  one  side  of  the  tongue  and  ichthyosis  on  the  other. 
Even  after  excision  of  an  epitheliomatous  tongue  the  stump 
may  become  ichthyotic  and  the  disease  not  recur  in  it. 

Epithelioma  when  it  attacks  the  tongue  usually  destroys 
life  quickly ;  the  lymph  glands  in  the  neck  are  soon  infected, 
and  as  a  rule,  the  disease  runs  its  course  in  about  a  year. 
The  average  duration  of  life  varies  from  six  to  twenty-four 
months. 


200  EPITHELIAL   TUMOURH. 

Death  ensues  in  a  large  proportion  of  cases  from  exhaus- 
tion, the  result  of  pain,  distress  of  mind,  and  difficulty  in 
taking  food ;  in  a  few  it  occurs  from  septic  pneumonia,  the 
result  of  inhaling  the  foetid  discharges  from  the  mouth  ;  a 
few  die  early  from  haemorrhage  when  the  ulceration  opens  up 
the  lingual,  or  the  carotid  artery.  Death  is  occasionally  due 
to  asphyxia.  This  may  arise  from  two  causes  ;  the  epithelioma 
may  extend  to  the  base  of  the  tongue  and  infiltrate  the  epi- 
glottis and  its  folds,  producing  oedema  of  the  glottis,  or,  a 
mass  of  enlarged  glands  in  the  neck  may  press  upon  the 
trachea  and  cause  suffocation. 

In  addition  to  the  tongue  and  lips,  epithelioma  may  begin 
in  the  mucous  membrane  of  the  cheek,  the  g'ums,  soft  palate, 
the  tonsils,  and  pharynx. 

In  the  case  of  the  cheek  epithelioma  is  sometimes  preceded 
by  a  patch  of  leukoplakia,  as  in  the  case  of  the  tongue. 
The  disease  often  starts  close  to  the  angle  of  the  mouth,  and 
extends  backwards  into  the  cheek  ;  or  it  begins  in  the  fold  of 
mucous  membrane  between  the  gum  and  the  cheek,  and 
occasionally  it  starts  in  the  centre  of  the  cheek,  often  on  a 
level  with  the  meeting-place  of  the  crowns  of  the  upper  and 
lower  molar  teeth. 

Ej)ithelioma  may  begin  in  any  part  of  the  gum,  but  it 
appears  more  frequently  in  the  mucous  membrane  covering  the 
lower  than  in  that  covering  the  upper  alveolar  processes.  The 
disease  often  starts  near  the  stump  of  a  carious  tooth,  and 
quickly  infiltrates  the  adjacent  mucous  membrane;  thus,  whilst 
it  is  eroding  the  bone,  it  is  creeping  along  the  mucous  mem- 
brane towards  the  cheek  on  one  side  and  the  tongue  on  the 
other.  It  is  astonishing  hoAv  epithelioma  erodes  such  a  firm 
and  compact  bone  as  the  mandible.  Similar  effects  may  be 
observed  when  the  disease  attacks  the  gums  in  relation  with 
the  maxilla ;  as  the  alveolar  process  is  destroyed  the  cavity  of 
the  antrum  is  exposed,  and  a  foul  ulcerating  chasm  formed. 
One  of  the  facts  connected  with  epithelioma  of  the  mucous 
membrane  of  the  mouth — and  it  matters  little  whether  the 
disease  begins  on  the  tongue,  cheek,  hard  or  soft  palate,  or 
gums — is  the  extraordinary  size  which  the  infected  lymph 
glands  in  the  neck  sometimes  attain,  whilst  the  ulcer  scarcely 
exceeds  1  cm.  in  diameter.     This  is  worth  bearing  in  mind, 


EFITIIELIOilA.  201 

because  an  enlargement  of  the  cervical  lymph  glands  in 
individuals  past  middle  age  should  always  induce  the  surgeon 
to  examine  the  various  recesses  of  the  mouth  and  fauces  for 
small,  inconspicuous  epitheliomatous  ulcers,  and  with  every 
care  they  sometimes  escape  detection  during  life.  It  is  neces- 
sary to  emphasise  this,  because  a  good  deal  has  been  written 
about  "  branchiogenous  cancer,"  or,  as  it  is  sometimes  called, 
"malignant  cyst"  of  the  neck.  The  tumour  is  most  com- 
monly observed  after  the  age  of  fifty,  and  is  deeply  seated  in 
the  neck,  usually  near  the  fork  of  the  carotid:  it  grows  with 
great  rapidity,  and  in  many  cases  softens  in  the  centre  and 
gives  rise  to  fluctuation.  The  overlying  skin  becomes  brawny 
and  red,  and  the  resemblance  to  an  abscess  is  so  striking  that, 
in  several  cases,  I  have  known  a  knife  to  be  used  under  this 
impression.  Gradually  the  implicated  skin  sloughs,  and  then 
an  epitheliomatous  chasm  forms  in  the  neck.  Microscopically 
the  tissue  of  these  tumours  is  characteristic  of  epithelioma. 
Some  writers  are  of  opinion  that  these  are  primary  epitheliomata 
arising  in  remnants  of  branchial  clefts.  My  belief  is  that,  in 
most  of  the  cases,  these  gland  masses  are  secondary  to  epithe- 
liomata originating  in  recesses  of  the  pharynx  or  naso-pharynx, 
and  the  theory  that  they  arise  in  remnants  of  branchial  clefts 
is  pure  fiction.  They  run  a  rapidly  fatal  course  :  the  average 
duration  of  life  is  about  six  months.  These  tumours  resent 
interference,  and  in  the  few  cases  where  patients  have  survived 
operation  quick  recurrence  has  been  the  rule. 

Treatment. — The  results  of  the  operative  treatment  of  epi- 
thelioma of  the  tongue  stand  in  strikmg  contrast  to  those  which 
follow  operations  for  this  disease  when  aflfecting  the  lower  lip. 

The  manner  of  removing  an  epitheliomatous  tongue  is 
modified  according  to  the  situation  and  extent  of  the  disease. 
The  excision  of  the  anterior  portion  of  the  tongue,  or  the  right 
or  left  anterior  fourth  of  the  organ  when  the  disease  is  localised 
to  one  side,  is  an  operation  devoid  of  risk  or  difiiculty.  When 
the  disease  deeply  invades  the  tongue,  involves  the  floor  of  the 
mouth,  or  extends  so  far  backwards  that,  in  order  to  get  beyond 
the  limits  of  the  disease,  the  surgeon  interferes  with  the  pillar 
of  the  fauces,  then  the  operation  is  often  hazardous.  The  chief 
difiiculty  is  connected  with  haemorrhage,  and  in  order  to 
obviate  it  a  variety  of  methods  have  been  advocated  for  the 


202  EPITHELIAL   TUMOURS. 

excision  of  the  tongue.  Tims  some  prefer  to  slowly  crush 
through  the  tissues  with  the  Avire  or  wire-rope  of  an  ecraseur ; 
others  use  a  galvano-cautery ;  many  deliberately  cut  through 
the  tissues  with  scissors  and  seize  the  divided  lingual  arteries 
with  forceps.  It  is  a  good  plan  (and  one  which  has  in  my  own 
practice  been  very  successful)  to  tie  both  lingual  arteries 
through  incisions  in  the  neck  ;  the  tongue  can  then  be  cut  out 
with  scissors  without  any  risk  of  hsemorrhage.  In  this  way 
infected  submaxillary  lymph  glands,  if  any  exist,  can  be  dis- 
sected out  through  the  same  incisions,  and  it  is  sometimes 
convenient  to  remove  the  submaxillary  salivary  glands.  The 
advantage  of  preliminary  ligature  of  the  lingual  arteries  is  two- 
fold ;  not  only  is  it  a  guarantee  against  haemorrhage,  but  it  so 
limits  the  blood  supply  of  the  part  that  it  reduces  sloughing 
and  foetor  to  a  minimum  and  retards  recurrence.  The  removal 
of  the  salivary  glands  relieves  the  patient  of  the  profuse 
salivation  which  is  such  a  source  of  discomfort. 

When  the  disease  is  very  extensive  it  is  necessary  to  acquire 
space  for  manipidation  by  slitting  the  cheek.  When  the  man- 
dible is  involved  the  diseased  part  must  be  excised  with  the 
tongue,  and  in  exceptional  cases  it  is  necessary  to  obtam  a  free 
removal  of  the  floor  of  the  mouth  by  means  of  incisions  between 
the  symphysis  and  the  hyoid  bone.  Mr.  Butlin,  in  his  work  on 
the  "  Surgery  of  the  Tongue,"  mentions  a  score  of  methods 
that  have  been  employed  in  dealing  with  epithelioma  of 
this  organ. 

It  is  an  important  point  in  operating  upon  the  tongue  to 
avoid  the  entrance  of  blood  into  the  trachea,  as  it  is  then 
drawn,  during  inspiration,  into  the  lungs  and  gives  rise  to 
septic  pneumonia.  Should  blood  in  considerable  quantity  get 
into  the  trachea  it  may  cause  suffocation.  To  avoid  these 
complications  it  is  useful,  in  extensive  operations  on  the  tongue, 
to  perform  laryngotomy  and  administer  the  ana3sthetic  through 
a  laryngotomy  tube,  and  in  order  to  prevent  blood  from  getting 
into  the  trachea,  the  pharynx  is  plugged  with  a  sponge. 

The  mortality  of  operations  for  the  removal  of  epithelio- 
matous  tongues  is  not  less  than  ten  per  cent.;  the  chief  causes 
of  death  are  hsemorrhage,  septic  pneumonia,  and  asthenia. 

Although  after  excision  of  an  epithelioma  of  the  tongue, 
recurrence  in  the  stump  or  cervical  lymph  glands  within  a 


EPITHELIOMA.  203 

year  of  the  operation  is  the  rule,  nevertheless  it  is  in  some 
cases  delayed  for  five  and  even  seven  years.  It  is  also  useful 
to  bear  in  mind  that,  in  some  cases,  Avhere  the  disease  is  ad- 
vanced and  too  extensive  to  admit  of  removal,  the  pain  may 
be  relieved  by  division  of  the  lingual  nerve,  and  a  few 
patients  are  rendered  comfortable  by  ligature  of  the  lingual 
and  facial  arteries. 

It  has  been  already  mentioned  that  epithelioma  occurring 
in  the  gums  will  afterAvards  invade  the  mandible  or  maxilla, 
according  to  its  situation.  Although  in  the  majority  of  in- 
stances in  which  the  maxilla  is  implicated  in  an  epithelioma, 
the  disease  begins  in  the  gingival  mucous  inembrane,  there  is 
a  small  number  of  cases  in  which  patients  past  middle  Hfe 
complain  of  pain  in  the  jaw  for  which  no  adequate  cause  can 
be  assigned.  Gradually  a  slight  fulness  is  observed  in  the 
infra-orbital  region,  with  perhaps,  cedema  of  the  eyelid :  the 
skin  becomes  brawny,  and  at  last  an  epitheliomatous  ulcer 
appears  in  the  skin  of  the  cheek,  and  the  antrum  is  then  found 
to  be  filled  with  a  tumour.  When  such  a  case  is  submitted  to 
operation  and  the  skin  of  the  cheek  reflected,  the  extensive  in- 
roads the  disease  has  been  silently  making  on  the  surrounding 
parts  is  truly  extraordinary.  The  greater  part  of  the  maxiUa 
will  be  found  destroyed,  and  outrunners  from  the  growth  will 
be  found  in  the  orbit  and  among  the  pterygoid  muscles.  The 
skin  of  the  cheek  is  usually  so  infiltrated  that  it  must  be  re- 
moved. The  successful  treatment  of  such  cases  demands  much 
boldness  on  the  part  of  the  operator,  as  he  will  find  it  necessary 
to  sacrifice  the  eye  and  the  orbital  contents,  the  palatine  aspect 
of  the  maxilla,  and  a  portion  of  the  skin  covering  the  cheek ; 
as  a  result,  a  large  yawning  cavern  is  left.  Life  is  rarely  pro- 
longed, but  the  patients  are  spared  much  pain  and  discomfort. 
This  is  the  variety  which  Reclus*  called  "  Epithelioma  tere- 
brant,"  and  is  usually  rendered  in  English  as  "  Boring  epithe- 
lioma." It  is  certainly  an  excessively  malignant  and  extremely 
insidious  variety  of  epithelioma. 

EPITHELIOMA    OF    THE    (ESOPHAGUS. 

This  disease  is  four  times  more  frequent  in  males  than 
in  females,  and  is  most  common  between  the  fortieth  and 

■■•'  Proc/res  Medical,  1876,  t.  iv. ,  p.  795. 


204  EPITHELIAL    TUMOUItS. 

sixtieth  years.  It  has  been  observed  as  early  as  the  thirtieth 
year,  and  my  oldest  case  was  eighty-four.  Certain  parts  of 
the  oesophagus  are  more  Hable  to  be  attacked  than  others  ; 
the  usual  situations  are :  1,  at  the  level  of  the  cricoid 
cartilage ;  2,  where  it  is  crossed  by  the  left  bronchus ;  3,  at 
its  termination. 

Nothing  is  known  of  the  early  stages  of  oesophageal  epithe- 
lioma, as  it  produces  few  symptoms  until  neighbouring  struc- 
tures, such  as  the  larynx,  trachea,  pleura,  etc.,  are  implicated. 

The  disease  runs  a  very  rapid  course;  most  cases  terminate 
fatally  within  a  year  from  the  time  the  patient  comes  under 
observation.  Death  occurs  in  a  variety  of  ways :  inanition  and 
exhaustion  are  the  results  of  obstruction  to  the  passage  of  food; 
pleurisy  and  septic  pneumonia,  due  to  perforation  of  the  pleura 
and  trachea.  A  fistula  between  the  trachea  and  oesophagus 
is  the  rule  in  this  disease.  Mediastinal  abscess,  which  may 
perforate  the  pleurae  or  pericardium,  sometimes  forms,  and 
ulceration  has  been  known  to  broach  the  aorta.  When 
epithelioma  begins  at  the  commencement  of  the  oesophagus, 
the  recurrent  laryngeal  nerves  are  apt  to  become  entangled 
and  cause  paralysis  of  the  laryngeal  muscles. 

When  the  disease  occupies  the  middle  and  lower  parts 
of  the  oesophagus,  the  lymph  glands  of  the  mediastinum  and 
lumbar  region  enlarge.  When  the  upper  third  of  the  tube  is 
implicated  the  mediastinal  glands  and  those  at  the  root  of  the 
neck  are  involved.  It  does  not  necessarily  follow  that  the 
glands  nearest  the  seat  of  disease  are  those  most  enlarged, 
for  it  occasionally  happens  that  the  neighbouring  glands  are 
apparently  unaffected,  whilst  those  at  some  little  distance  are 
charged  with  epitheliomatous  material.  For  instance,  in  a  case 
in  which  a  man  died  from  a  large  epithelioma  of  the  middle 
third  of  the  oesophagus,  the  mediastinal  glands  were  slightly 
bigger  than  usual ;  but  in  the  neck,  immediately  above  the 
clavicle,  there  was  one  hard  gland,  the  size  of  a  bean,  just  beneath 
the  skin.  The  enlargement  of  this  gland  was  regarded,  in  the 
presence  of  other  signs,  as  an  indication  of  the  malignant 
nature  of  the  oesophageal  stricture.  Dissemination  is  rare  in 
epithelioma  of  the  oesophagus. 

Treatment. — The  peculiar  relations  of  the  oesophagus 
render  it  impossible  to  carry  out  with  any  prospect  of  success 


EPITHELIOMA.  205 

excision  of  an  epithelioma.  The  inability  to  swallow  food  and 
the  almost  inevitable  fate,  death  from  starvation,  has  induced 
surgeons  to  perform  gastrostomy.  The  results  of  this  opera- 
tion for  oesophageal  epithelioma  are  not  encouraging. 

EPITHELIOMA    OF    THE    LARYNX. 

When  this  disease  originates  in  the  mucous  membrane  of 
the  ventricles,  vocal  cords,  or  ventricular  bands  it  is  said  to  be 
intrinsic.  When  epithelioma  arises  in  the  aryteno-epiglottic 
folds,  or  the  mucous  membrane  covering  the  arytenoids  or 
the  inter-arytenoid  folds,  it  is  said  to  be  extrinsic. 

In  addition,  the  larynx  may  be  implicated  in  extensive 
epithelioma  of  the  tongue,  fauces,  or  upper  part  of  the  oeso- 
phagus. 

Intrinsic  epithelioma  of  the  larynx  usually  commences  in 
one  of  the  ventricles,  and  is  almost  invariably  of  the  warty 
variety ;  it  is  particularly  rich  in  cell-nests,  and  these  are 
exceptionally  horny.  The  papillomatous  character  of  intrinsic 
laryngeal  epithelioma  must  be  borne  in  mind,  or  it  may  lead 
to  grave  errors  in  diagnosis.  The  laryngeal  wart  is  essentially 
a  disease  of  children  and  young  adults,  whereas  epithelioma 
is  an  affection  of  adults,  especially  men  who  have  passed  the 
meridian  of  life.  A  wart-like  growth  in  the  larynx  of  an 
individual  over  forty  years  of  life  should  be  viewed  with 
suspicion.  As  a  rule,  ulceration  and  infection  of  lymph  glands 
occur  early  in  the  course  of  the  disease. 

Laryngeal  epithelioma  is  usually  rapid  in  its  progress ; 
death  occurs  in  from  twelve  to  eighteen  months,  and  is  rarely 
prolonged  beyond  two  years.  The  fatal  result  is  due  to 
asthenia,  which  is  intensified  by  the  difficulty  these  patients 
experience  in  swallowing,  and  pneumonia.  Actual  suffocation 
is  obviated  early  in  the  course  of  the  disease  by  tracheotomy. 

Extrinsic  epithelioma  of  the  larynx  appears  to  be  a  far 
more  formidable  affection  than  the  intrinsic  form.  It  not 
only  extends  more  rapidly  and  infects  the  lymph  glands  at  a 
very  early  period,  but  implicates  the  surrounding  parts  far 
more  extensively  than  the  intrinsic  variety ;  the  duration  of 
life  is  therefore  shorter.  Dissemination  is  extremely  rare  in 
laryngeal  epithelioma. 

Treatment. — It  is  of  great  importance  to  recognise  early 
the  nature  of  this  grave  disease  of  the  larynx  ;  as  a  rule,  there 


206  EI'ITIIEJJAL    TUMOURS. 

is  little  difficulty  in  appreciating  the  extrinsic  variety,  but  the 
papillomatous  nature  of  intrinsic  epithelioma  of  the  larynx 
makes  the  diagnosis  somewhat  dubious  in  the  early  stages. 
Thus  it  is  customar}^  Avhen  there  is  an  element  of  doubt  as  to 
the  nature  of  a  laryngeal  growth  in  an  adult,  to  remove  a 
fragment  by  means  of  laryngeal  forceps  and  submit  it  to 
microscopical  examination. 

Acting  on  the  principles  that  prevail  in  the  treatment  of 
epithelioma  in  other  parts  of  the  body,  surgeons  have  in 
recent  years  (following  the  lead  of  Billroth,  1873)  attempted 
to  cure  epithelioma  of  the  larynx  by  excision.  Unfortunately 
there  is  very  little  to  urge  in  favour  of  complete  extirpation 
of  the  larynx  for  intrinsic  epithelioma ;  it  has  been  abandoned 
by  most  surgeons  in  the  extrinsic  form  of  the  disease,  and 
even  for  the  intrinsic  form  laryngectomy  is  fast  falling  into 
disfavour.  The  operation  has  an  excessively  high  mortality, 
a  very  large  proportion  of  the  patients  succumb  to  septic 
pneumonia,  and  the  few  that  recover  are  often  in  a  miserable 
and  pitiable  condition. 

Excision  of  a  lateral  half  of  the  larynx  for  intrinsic  epi- 
thelioma is  a  much  more  successful  operation,  and  this  is  also 
true  of  the  operation  known  as  thyrotomy,  in  which  the 
thyroid  cartilage  is  divided  in  the  median  line  and  the  diseased 
soft  tissues  are  dissected  out  or  destroyed  by  a  galvano-cautery. 

Although  partial  excision  of  the  larynx  is  a  fairly  satis- 
factory operation,  the  opinion  is  gaining  ground  among 
surgeons  that  the  needs  of  the  patient  are  in  most  cases  best 
satisfied  by  a  simple  tracheotomy. 

EPITHELIOMA   OF   THE    PINNA. 

This  is  a  very  unusual  situation  for  epithelioma.  Some 
carefully  described  cases  will  be  found  in  the  records  of  the 
Pathological  Society,  London.  The  disease  may  begin  in  any 
part  of  this  appendage.  So  far  it  has  been  mauily  observed 
in  individuals  advanced  in  years,  and  attacks  men  and  women 
equally.  After  destroying  the  pinna  it  attacks  the  bony  wall 
of  the  skull.  Its  disastrous  effects  are  well  illustrated  in  a 
case  described  by  Hulke.* 

*  Trans.  Path.  Soc,  vol.  xxvi.  187.  {See  also  Bowlby,  ibid.,  vol.  xxxv.  330, 
and  R.  Williams,  xxxv.  331.) 


207 


CHAPTER    XXII. 

EPITHELIOMA  {concluded). 

EPITHELIOMA   OF   THE    GENITO-URINARY   ORGANS. 

Epithelioma  of  the  Scrotiiin  or  Ghiinney -Sweep  s  Cancer 
appears  on  the  scrotum  in  the  form  of  a  Avart  or  warts ;  they 
are  often  spoken  of  as  soot-warts,  for  they  not  only  occur 
on  the  scrotum  of  the  chimnej^-sweep,  but  are  met  with  in 
men  who  are  brought  much  in  contact  with  soot.  In 
many  cases  the  scrotal  wart  is  harmless,  but  in  a  certain 
proportion  of  cases  it  grows  slowly,  or  if  they  are  multiple, 
one  of  them  becomes  more  prominent  than  its  fellows 
and  ulcerates.  The  ulceration,  at  first  limited  to  the  wart, 
extends  to  the  surrounding  skin  and  forms  an  epithelio- 
matous  ulcer,  which  will  extensively  involve  the  skin  of  the 
scrotum,  and  spread  thence  to  the  skin  around  the  anus  and 
pubes,  and  even  to  the  thigh. 

In  some  cases  the  ulceration,  instead  of  spreading  widely, 
involves  the  tissues  deeply,  so  that  the  tunica  vaginalis  is 
exposed  and  sometimes  implicated  in  the  disease  ;  but  this  is 
rare. 

The  inguinal  glands  become  infected  and  attain  a  large 
size,  then  slowly  involve  the  skin,  break  down,  and  ulcerate ; 
this  process  often  leads  to  the  formation  of  deep  excavations 
in  the  groin,  and  it  not  infrequently  happens  that  the  femoral, 
or  external  ihac  artery,  or  both  will  be  seen  exposed  and 
pulsating  on  the  floor  of  one  of  these  deep  pits.  It  is  not 
uncommon  in  such  cases  for  the  ulceration  to  open  up  one 
of  these  laro-e  vessels,  and  violent  fatal  hsemorrhas'e  is  the 
result. 

It  has  been  stated  by  several  writers  that  in  chimney- 
sweeps epithelioma  may  begin  in  the  inguinal  glands.  There 
can  be  little  doubt  that  such  views  arise  in  imperfect 
observation.  In  some  of  these  cases  the  lesion  on  the  scrotum 
assumes  the  form  of  a  small  hemispherical  pimple  no  larger 
than  a  split  pea,  so  small  indeed  that  I  have  known  them  to 
escape  very  vigilant  eyes ;  and  yet  such  a  small  lesion  will 


208  EPITHELIAL   TUMOURH. 

cause  the  inguinal  glands  to  grow  into  a  mass  as  big  as  two 
fists.     Two  such  cases  have  come  under  my  own  notice. 

A  very  remarkable  feature  connected  with  epithelioma  in 
English  chimney-sweeps  is,  that  they  are  not  more  prone  to  it 
in  other  parts  of  their  bodies  than  those  persons  who  follow 
other  occupations  ;  yet  the  scrotum,  which  in  other  individuals 
is  the  part  least  disposed  to  epithelioma,  is  in  sw^eeps  so  very 
liable  to  become  the  seat  of  this  disease.  No  answer  to  this 
problem  is  at  present  forthcoming ;  neither  has  anyone  suc- 
ceeded in  assigning  a  reason  why  it  is  so  very  much  more 
frequent  in  English  chimney-sweeps  than  in  sweeps  of  other 
nations.* 

There  is  good  reason  to  believe  that  tar  and  paraffin  are 
liable  to  produce  an  affection  of  the  scrotum,  similar  to  the 
epithelioma  of  chimney-sweeps.  Such  cases  are,  however, 
very  rare.     The  literature  has  been  summarised  by  Butlin.t 

Treatment. — This  consists  in  the  free  removal  of  the 
disease  whenever  it  is  practicable  ;  the  very  best  results  follow 
the  excision  of  a  soot-wart  in  its  earliest  stages.  When  the 
disease  is  permitted  to  extend  deeply  into  the  tissues  of  the 
scrotum  so  that  it  is  necessary  to  excise  one  or  both  testicles 
with  the  scrotum,  and  perhaps  a  portion  of  the  neighbouring 
skin,  it  is  not  probable  that  lasting  benefit  will  follow  the 
operation.  In  cases  where  soot-warts  have  been  early  and 
thoroughly  removed  there  is  good  ground  for  the  belief  that  a 
cure  is  sometimes  brought  about. 

Epithelioma  of  the  Penis  and  Urethra. — Epithelioma  may 
attack  the  prepuce  or  the  epithelial  investment  of  the  gians. 
The  disease  is  excessively  rare  before  the  age  of  thirty  years, 
and  appears  to  be  most  common  between  the  ages  of  fifty  and 
seventy.  There  is  reason  to  believe  that  phimosis,  congenital 
and  acquired,  is  a  condition  that  favours  the  development 
of  epithelioma  of  the  penis.  It  is  certamly  true  that  phimosis, 
by  leadmg  to  the  retention  of  smegma,  is  indirectly  a  cause  of 
penile  warts  not  only  in  men  but  other  mammals,  especially 
horses  and  bulls.  Mention  has  already  been  made  of  the  fact 
that  penile  warts  are  particularly  prone  to  be  transformed 
into  wart  horns,  and  cases  have  been  recorded  in  which  men 

*  Butlin,  Brit.  lied.  Journal,  1892,  vol.  i,  1341. 
t  Brif.  Med.  Journal,  1892,  vol.  ii.  p.  68. 


EPITHELIOMA.  209 

have  had  a  wart  horn  on  the  penis  for  several  years,  and  at 
length  the  base  has  ulcerated  and  epithelioma  developed. 
Gould*  has  described  a  good  example  of  this,  which  is  further 
peculiar  in  that  the  wart  and  ulceration  appeared  to  start  in  a 
scar  left  by  circumcision.  It  must  be  remembered  that  epithe- 
lioma may  begin  as  an  ulcer  on  the  penis,  but  the  warty  variet}^ 
is  by  far  the  most  frequent.  When  the  disease  begins  as  an 
ulcer  it  is  very  liable  to  be  mistaken  for  some  manifestation 
of  primary  or  tertiary  syphilis. 

Epithelioma  in  whatever  form  it  commences  gradually 
involves  and  as  surely  destroys  the  penis,  implicates  the 
scrotum,  and  infects  the  inguinal  lymph  glands  on  each  side  ; 
in  many  cases  the  lumbar  glands  also  become  infected. 
Secondary  deposits  seem  to  be  rare.  The  duration  of  life  in 
this  disease  is  very  uncertain.  As  a  rule,  its  course  is  short — 
six  months  to  a  year ;  but  in  many  cases  it  is  much  longer. 
When  the  urethra  is  involved  this  passage  is  liable  to  become 
narrowed,  and  not  infrequently  urinary  listulaB  add  to  the 
patient's  misery. 

Epithelioma  of  the  Urethra. — Judging  from  the  scanty 
records  obtainable,  primary  cancer  of  the  urethra  is  very  rare. 
It  is  possible  that  the  disease  is  more  frequent  than  we  imagine, 
as  it  is  an  affection  very  likely  to  be  mistaken  for  perineal 
abscess.  The  disease  in  all  the  recorded  cases  commenced  in 
that  section  of  the  tube  which  is  in  relation  with  the  bulb. 

In  the  reported  cases  where  the  details  are  given  with 
sufficient  care,  and  the  nature  of  the  tumour  is  confirmed  by 
microscopical  examination,  the  features  of  the  disease  are  as 
follows  : — 

The  patients  were  men  between  the  ages  of  fifty  and 
seventy-three  ;  they  had  all  suifered  from  gonorrhoea  in  youth, 
but  urethral  stricture  did  not  follow  as  a  sequence.  The 
trouble  began  by  the  formation  of  a  hard  mass  in  the  perineum 
in  relation  with  the  bulb  and  corpora  cavernosa.  This  mass 
led  to  interference  with  micturition,  and  attempts  to  pass 
a  catheter  provoked  intense  pain  and  free  haemorrhage  from 
the  urethra.  The  obstruction  increased  until  the  urethra 
became  impermeable  to  instruments,  the  overlying  skin  was 
involved,   and  fistulse  formed  in  the  perineum.     In  most  of 

*  Trans.  Path.  Soc,  xxxviii.  355. 


210  ET'ITHELTAL    TUMOUUH. 

the  cases  perineal  section  was  perfornied,  and  the  cut  surface 
of  the  tumour  had  a  greyish-white  appearance,  and  the  tissue 
was  extremely  brittle.  This  tissue  presented  under  the  micro- 
scope the  characters  typical  of  squamous-cellecl  epithelioma 
with  abundant  cell-nests.  As  a  rule,  the  lymph  glands  are 
not  enlarged,  and  secondary  deposits  are  rare.* 

Treatment. — Epithelioma  of  the  penis  is  treated  by  partial 
or  complete  removal  of  this  organ  according  to  the  extent  of 
the  disease.  Partial  removal  of  the  penis,  whether  by  knife, 
cautery,  or  ecraseur  (of  the  three  methods  that  in  which  the 
knife  is  employed  is  the  best)  is  a  simple  proceeding,  and 
entails  but  little  risk  so  long  as  the  cut  end  of  the  urethra  is 
stitched  to  the  skin.  When  the  disease  is  so  extensive  as  to 
demand  complete  removal  of  the  penis,  the  operation  which 
gives  best  results  consists  in  excising  not  only  the  corpus 
spongiosum  and  corpora  cavernosa,  but  the  penile  crura  as 
well  by  detaching  them  from  the  pubic  arch.  The  urethra 
is  brought  out  and  attached  to  the  incision  in  the  perineum. 
The  published  results  of  this  complete  operation  are  very 
good,  and  my  experience  of  it  has  been  in  every  way  satis- 
factory. The  ultimate  results  of  amputation  of  the  penis  are 
more  favourable  after  partial  than  after  complete  removal  of 
organ,  simply  because  the  disease  is  not  so  advanced  when 
partial  amputation  is  sufficient. 

In  regard  to  epithelioma  of  the  urethra,  sufficient  evidence 
is  not  yet  accessible  to  enable  a  decision  to  be  formed  as  to  the 
most  appropriate  treatment. 

Epithelioma  of  the  Bladder. — Epithelioma  occasionally 
attacks  the  vesical  mucous  membrane,  and  it  does  not  appear 
to  exhibit  a  predilection  for  any  particular  part  of  it.  From 
what  is  laiown  of  the  habits  of  this  disease  elsewhere,  it  would 
be  anticipated  that  in  a  certain  proportion  of  cases  it  would 
begin  at  the  orifices  of  the  ureters.  This  is  actually  the  case ; 
but  it  must  not  be  assumed  that  when  the  ureteral  orifices  are 
found  involved  in  the  late  stages  of  the  disease  that  the 
epithelioma  originated  at  these  orifices. 

Epithelioma  of  the  bladder  seems  to  be  more  common  in 
women  than  in  men.    The  signs  of  its  presence  are  hsematuria, 

*  J.  Griffiths,  Trans.  Path.  Soc,  vol.  xl.  177  ;  Marcus  Beck,  "  International 
Clinics,"  vol.  ii.  256  ;   and  Witsenhausen,  Bruns,  Beitrcige,  bd.  vii.  571. 


EPITHELIOMA.  211 

painful  micturition,  and  cystitis.  Such  signs  are,  of  course, 
equivocal,  and  it  is  usual  to  demonstrate  its  existence  by  means 
of  the  cystoscope,  or  a  cystotomy  in  men,  and  dilatation  of  the 
urethra  in  women.  It  is  very  unusual  before  the  age  of  forty. 
Death  results  from  renal  complications,  exhaustion  from 
repeated  bleeding,  bodily  suflering,  and  frequent  micturition. 

Epithelioma  of  the  Female  Genitalia. — The  female  genital 
organs  liable  to  epithelioma  are  the  labia  majora  and  minora, 
the  clitoris,  vagina,  and  that  portion  of  the  cervix  of  the  uterus 
which  projects  into  the  vagina. 

Collectively,  epithelioma  of  these  parts  is  by  no  means  in- 
frequent; when  each  part  is  individually  considered,  epithelioma 
is  somewhat  rare.  This  disease  is  more  frequent  in  the  labia 
than  in  all  the  parts  of  the  genital  passage  taken  together. 

The  Labia  Majora  and  Minora. — Epithelioma  may  begin 
in  any  part  of  the  labia ;  its  course,  relation  to  lymph  glands, 
and  modes  by  which  it  causes  death  are  very  similar  to  epithe- 
lioma of  the  scrotum.  It  is  a  curious  fact  that  two  cases  of 
cancer  of  the  labium  have  come  under  my  notice  in  patients 
who  were  wives  of  chimney-sweeps. 

The  Clitoris. — Epithelioma  of  this  organ  is  very  rare  indeed. 
In  the  only  case  that  has  come  under  my  notice  the  disease 
began  at  the  extremity  of  the  clitoris ;  the  lymph  glands  in 
each  ino-uinal  reo-ion  were  enlarged. 

Vagina. — Epithelioma  may  make  its  appearance  in  any 
part  of  the  mucous  membrane  lining  this  canal,  but  it  is  much 
more  liable  to  begin  at  the  junction  of  the  vagina  with  the 
vulva,  and  on  that  portion  which  is  reflected  over  the  uterine 
cervix.  In  many  cases  in  which  the  vulval  extremity  of  the 
vagina  is  invaded  by  epithelioma  the  disease  begins  at,  or  in 
close  proximity  to  the  urethral  orifice  and  extends  into  the 
vagina.  In  such  cases  the  inguinal  lymph  glands  are  infected 
very  early,  and  the  ulceration  destroys  the  vesico- vaginal 
septum  and  perforates  the  posterior  wall  of  the  bladder. 

When  the  posterior  wall  of  the  vagina  is  the  seat  of  epi- 
thelioma the  recto-vaginal  septum  becomes  infiltrated;  ulcera- 
tion ensues,  and  leads  to  the  formation  of  a  recto-vagfina, 
fistula. 

It  is  very  remarkable  that  in  its  early  stages  epithelioma 
produces  such  slight  inconvenience  that  the  patients  rarely 


212  EPITUELIAL    TUMOUliS. 

seek  advice  until  the  disease  has  long  passed  beyond  the 
bounds  of  operative  interference.  This  is  especiall}^  the  case 
when  it  attacks  the  vaginal  portion  of  the  cervix  uteri,  and  it  is 
on  this  account  that  so  few  opportunities  arise  for  studying  its 
early  stages. 

The  epithelial  investment  of  the  uterine  cervix  derived 
from  the  vagina  is  continuous,  at  the  margin  of  the  os  uteri, 
with  the  columnar  cells  lining  the  cervical  canal.  The  layer 
of  squamous  epithelium  covering  the  vaginal  surface  of  the 
cervix  has  been  compared  to  "  a  tailor's  thimble  which  fits 
on  the  lower  end  of  the  cervix  projDer  "  ( Williams).  Epithelioma 
may  begin  at  any  point  from  the  os  uteri  to  the  vaginal  vault. 
In  the  earliest  stages  at  which  it  comes  under  observation 
the  disease  assumes  the  form  of  a  circular  ulcer  with  raised  and 
everted  edges,  as  is  seen  in  many  epitheliomata  of  the  lips ; 
sometimes  it  erodes  deeply  from  the  beginning ;  and  excep- 
tionally it  forms  luxuriant  cauliflower  excrescences.  Thus  in  its 
naked-eye  characters,  as  well  as  in  its  minute  structure,  epithe- 
lioma of  the  vaginal  portion  of  the  uterine  neck  does  not  differ 
from  this  form  of  tumour  in  other  regions  of  the  body.  Gradu- 
ally the  disease  extends  from  the  cervix  to  the  vaginal  wall ;  it 
rarely  extends  into  the  cervical  canal,  but  it  quickly  involves 
the  connective  tissue  of  one  or  both  broad  ligaments. 
Gradually  the  structures  implicated  by  the  disease  ulcerate 
and  necrose.  When  these  destructive  changes  involve  the 
anterior  vaginal  wall  the  bladder  is  apt  to  be  perforated, 
and  a  urinary  fistula  adds  to  the  misery  of  the  patient.  In 
a  similar  way,  when  the  disease  invades  the  posterior  wall  of 
the  vagina  the  rectum  may  be  perforated.  In  some  cases,  in 
the  later  stages,  when  the  upper  segment  of  the  vagina  is 
destroyed,  the  bladder  and  rectum  may  both  communicate 
with  a  foul  ulcerating  chasm. 

Epithelioma  of  the  cervix  is  unusual  before  the  age  of 
thirty,  and  is  most  common  between  thirty-five  and  fifty-five. 

Treatment. — When  epithelioma  attacks  the  labia  and  its 
nature  is  recognised  before  it  has  had  time  to  spread  very 
extensively,  the  affected  tissues  must  be  freely  removed  with 
knife  and  cautery.  Should  the  inguinal  lymph  glands  be 
enlarged,  they  must  be  dissected  out. 

In  the  rare  instances  in  which  the  clitoris  is  attacked  with 


EPITHELIOMA.  213 

epithelioma  it  is  tlie  usual  practice  to  dissect  out  tliis  append- 
age with  its  crura.  In  the  case  of  the  vagina  the  patients  very 
rarely  submit  themselves  to  observation  at  a  sufficiently  early 
stage  of  the  disease  to  allow  a  satisfactory  operation  to  be  per- 
formed. When  epithelioma  spreads  to  the  recto-vaginal,  or 
the  vesico-vaginal  septum,  the  removal  of  the  disease  will  lead 
to  the  formation  of  a  fistula  between  rectum  and  vagina,  or 
between  bladder  and  vagina,  and  thus  anticipate,  in  a  measure, 
those  distressing  complications  which  are  almost  sure  to  be 
produced  in  the  course  of  the  disease. 

When  epithelioma  attacks  the  vaginal  portion  of  the 
uterine  cervix  and  is  seen  early,  prompt  removal  of  the  cervix 
will  do  much  to  delay  the  progress  of  the  disease.  Operations 
of  this  kind  have  a  limited  application,  because  they  can  only 
be  carried  out  when  the  disease  is  very  restricted,  on  account 
of  the  close  proximity  of  the  bladder  to  the  anterior  surface 
of  the  cervix.  Recurrence  usually  begins  at  the  cut  edge  of 
the  vaginal  mucous  membrane  and  spreads  into  the  vaginal 
fornices.  Removal  of  a  limited  epithelioma  from  the  cervix 
is  attended  with  very  little  risk  to  life. 

EPITHELIOMA    OF   THE   ANUS 

is  about  equal  in  frequency  to  this  disease  in  the  scrotum 
and  labia.  It  is  more  frequent  in  women  than  in  men,  and 
rarely  begins  before  the  fortieth  year.  In  about  half  the 
.cases  the  inguinal  glands  are  affected  on  one  or  both  sides. 
When  seen  in  the  early  stages  and  its  nature  recognised, 
epithelioma  of  the  anus  admits  of  free  and  complete 
removal,  and  the  results  of  such  interference  are  admir- 
able. In  cases  where  the  disease  runs  its  course  life  is  rarely 
prolonged  beyond  twelve  months ;  whereas  in  cases  where  the 
growth  is  satisfactorily  removed  life  has  been  prolonged  several 
years  (five  to  eight).  In  cases  where  the  disease  cannot  be 
extirpated,  the  patients  are  sometimes  made  more  comfortable 
by  diverting  the  course  of  the  fseces. 

EPITHELIOMA    OF   SCARS. 

Surgeons  have  long  been  aware  that  scars  left  by  burns 
are  liable  to  become  the  seat  of  epithelioma,  especially  when 
situated  on  the  limbs.     Scars  upon  the  legs  are  more  prone  to 


214  EPITHELIAL    TUMOURS. 

this  disease  tlian  those  on  the  arms.  When  epithehonia 
attacks  a  scar  the  change  usually  begins  near  the  junction 
of  the  skin  and  cicatricial  tissue ;  in  some  cases  the  disease 
extends  along  this  margin  and  encroaches  but  little  upon  the 
skin  on  one  side,  or  the  scar  on  the  other ;  more  commonly 
the  whole  cicatrix  is  quickly  involved,  and  a  large  ulcerating 
surface  with  raised  rampart-like  edges  results.  Histologically, 
this  variety  of  epithelioma  is  identical  with  that  which 
occurs  on  the  lips ;  it  involves  adjacent  tissues  and  the 
underlying  bone,  infects  the  neighbouring  lymph  glands,  and 
recurs  locally  after  removal.  When  a  limb  is  the  seat  of 
epithelioma,  and  amputation  is  performed,  the  disease  is  apt 
to  recur  in  the  stump. 

Scar  epithelioma  is  usually  less  malignant  than  the  same 
disease  in  the  lips,  tongue,  anus,  or  scrotum.  Many  chronic 
ulcers  occurring  in  connection  with  scars  in  adults  are  often 
clinically  described  as  epitheliomata.  In  collecting  evidence 
relating  to  this  question  no  case  should  be  classed  as  a  scar- 
epithelioTiia  ttnless  the  diagnosis  is  confirmed  by  a  careful 
histological  examination. 

Lupus  scars  are  also  liable  to  epithelioma.  Bayha*  has 
published  some  good  observations,  in  which  he  points  out  that 
this  sequel  of  lupus  is  most  prone  to  occur  between  the  fortieth 
and  the  sixtieth  years  ;  it  has,  however,  been  observed  in  a 
patient  of  fourteen  years.  Epithelioma  of  lupus  scars  has  been 
most  frequently  seen  on  the  face,  and  in  a  very  large  proportion 
of  cases  it  affects  the  skin  near  the  malar  bone. 

Treatment. — When  epithelioma  attacks  scars  situated  on 
the  limbs  it  is  the  usual  practice  to  perform  amputation  and 
the  results  are  satisfactory. 

When  the  disease  occurs  in  scars  seated  on  the  face,  free 
removal  with  the  knife  and  sharp  spoon,  accompanied  by 
thorough  destruction  of  the  implicated  tissue  by  means  of  the 
cautery,  gives  the  best  results. 

EPITHELIOMA   OF   THE    CONJUNCTIVA. 

It  is  very  rarely  that  epithelioma  attacks  the  conjunctiva ; 
when  it  occurs  in  this  mucous  membrane  the  disease  makes 

*  Brans,  BeUrclfje,  bd.   iii.,  s.    1  ;  and  Berry,  Trans.    Path.    Soc,  vol.   xlii. 
p.  308. 


EPITHELIOMA.  215 

its  appearance  as  a  pimple,  or  phlyctenule,  at  tlie  corneo- 
sclerotic  margin  on  the  outer  side  of  the  eyeball.  The 
majority  of  cases  of  epithelioma  of  the  conjunctiva  occur 
after  the  fiftieth  year,  but  it  has  been  reported  in  a  patient 
twenty-seven  years  of  age,  in  whom  it  supervened  upon  an 
injury  ;  the  man  received  a  scratch  upon  the  conjunctiva  from 
a  branch  of  a  tree,  and  a  few  months  later  a  small  tumour 
arose  between  the  caruncle  and  the  corneo-sclerotic  marsin.* 

o 

In  the  early  stages  e]3ithelioma  restricts  itself  to  the 
conjunctiva,  but  infiltrates  the  whole  thickness  of  this  mem- 
brane ;  even  in  the  later  stages  it  shows  little  tendency  to 
implicate  the  cornea  or  sclerotic,  but  invades  the  eyeball 
at  the  point  of  junction  of  the  cornea  and  sclerotic. 

Two  examples  of  conjunctival  epithelioma  that  came 
under  my  own  observation  occurred  in  the  cicatrices  left  by 
injuries  caused  by  lime.  In  one  case  the  eye  had  been  useless 
many  years. 

The  tumour  rarely  exceeds  a  nut  in  size,  but  before  it 
attains  the  dimensions,  of  a  pea  it  ulcerates  and  assumes  the 
appearance  characteristic  of  an  epitheliomatous  ulcer  elsewhere. 
When  the  tumour  is  excised,  quick  recurrence  is  the  rule. 
When  it  infects  lymph  glands  it  is  the  pre-auricular  set  which 
enlarge,  and  afterwards  those  in  the  submaxillary  region. 

Treatment. — As  the  disease  usually  recurs  very  quickly 
when  the  conjunctiva  alone  is  excised,  it  appears  advisable  to 
remove  the  disease  thoroughly  by  excising  the  eyeball  with 
the  conjunctiva.  When  the  eye  is  useless  in  consequence  of 
an  old  injury,  such  as  a  lime-burn,  there  should  be  no 
hesitation  in  sacrificing  the  globe.  If  the  pre-auricular  and 
submaxillary  lymph  glands  are  enlarged,  they  should  be 
enucleated  at  the  same  time  as  the  globe. 

EPITHELIOMA    OF    THE    GALL    BLADDER. 

There  is  a  fair  number  of  cases  recorded  in  medical 
literature  under  the  name  of  cancer  of  the  gaU  bladder,  but 
it  is  an  unfortunate  circumstance  that  very  few  of  the 
specimens  have  been  submitted  to  careful  microscopical 
examination.     Of  the  few  that  have  been  thus  investigated 

*  Lagrange,  "  De  I'epithelioma  de  la  conjunctive  bulbaire."     Soc.  FranQaise 
d'Ophtalmologie,  1892,  p.  7L 


216 


EPITHELIAL    TUMOURS. 


the  tumours  seem  to  be  epithelioixiata  rather  than  cancers ; 
hence  it  will  be  convenient,  until  more  careful  reports  are 
forthcoming,  to  deal  with  "  cancer  "  of  the  gall  bladder  in 
this  chapter. 

The  disease  presents  itself  as  a  uniform  thickening  of  the 
walls  of  the  gall  bladder,  which  causes  it  to  assume  a  pyriform 


Liver. 


Gall  stone. 


Tumour  of 
gall  bladder. 


Fig.  105. — Ex:)ithelioma  of  the  gall  bladder.    (Muse^iin,  Middlesex  Hospital.) 


shape  and  project  from  the  under  surface  of  the  liver.  In 
some  few  cases  the  tumour  has  attained  the  dimensions  of  a 
large  fist.  In  the  earl}^  stages  the  disease  is  confined  to  the 
gall  bladder,  but  later  it  invades  the  liver,  and  sometimes  the 
duodenum  and  stomach.  When  the  tumour  is  bisected  it 
presents  the  characters  displayed  in  Fig.  105.  In  the  middle 
of  the  tumour  there  is  usually  a  chamber  containing  biliary 
calculi,  representing  the  original  cavity  of  the  gall  bladder. 


EPITHELIOMA.  217 

It  is  an  interesting:  fact  that  calculi  are  found  in  more  than 
three-fourths  of  the  cases. 

Dissemination  is  rare.  When  it  occurs,  the  secondary 
nodules  are  found  in  the  liver.  In  several  cases  the  peri- 
toneum has  been  infected,  its  surface  being  dotted  with  an 
innumerable  number  of  minute  miliary  knots.  A  case  of  this 
kind  came  under  my  own  notice  ;  there  was  hydroperitoneum. 
The  lymph  glands  in  the  hilum  of  the  liver  are  often  infected. 

The  chief  clinical  features  of  "  cancer  "  of  the  gall  bladder 
may  be  thus  summarised  : — 

The  disease  is  most  frequent  between  the  fortieth  and 
sixtieth  years.  Jaundice  is  the  exception,  and  probably  occurs 
in  less  than  one-third  of  the  cases.  The  chief  signs  are  the 
presence  of  a  hard  but  tender  tumour  in  the  region  of  the 
gall  bladder  accompanied  by  epigastric  pain.* 

*  Musser  has  collected  the  chief  cases  in  the  Boston  Med.  and  Surg.  Journal, 
December  15,  1889  ;  and  Norman  Moore,  "  Visceral  New-Growths,"  p.  39. 


218 


CHAPTER    XXIII. 

ADENOMA   AND   CARCINOMA. 


An  adenoma  may  be  defined  as  a  tumour  constructed  upon 
the  type  of,  and  growing  in  connection  with  a  secreting  gland, 
but  difters  from  it  in  being  impotent  to  produce  the  secretion 
pecuhar  to  the  gland  it  mimics.     (Fig.  106.) 

Adenomata  occur  as  encapsuled  tumours  in  such  glands 
as  the  mamma,  parotid,  thyroid,  and  liver ;  in  the  mucous 
membrane  of  the  rectum,  intestine,  and  uterus  they  are 
pedunculated.  A  single  adenoma  may  be  present,  but  not 
infrequently  two  or  more  exist  in  the  same  gland.  In  the  case 
of  the  intestine  a  score  or  more  may  co-exist  in  the  same 
individual.  In  size  they  vary  greatly;  some  are  no  larger 
than  peas,  whereas  in  certain  situations — e.g.,  the  mamma — 
an  adenoma  will  occasionally  attain  the  dimensions  of  a  man's 
head,  and  in  the  case  of  the  ovary  an  adenoma  weighing  forty 
pounds  is  no  rarity ;  in  such  the  acini  are  usually  distended 
with  fluid. 

The  effects  of  adenomata  depend  mainly  upon  the  situations 
in  which  they  grow.  The  following  statements  are  true  for 
all : — -When  completely  removed  there  is  no  fear  of  recurrence  ; 
they  do  not  infect  neighbouring  lymph  glands,  nor  give  rise 
to  secondary  deposits.  When  an  adenoma  causes  death,  it  is 
in  consequence  of  mechanical  complications,  depending  on 
the  situation  and  size  of  the  tumour.  The  dangers  to  be 
apprehended  from  adenomata  will  be  mentioned  with  each 
species. 

Although  the  distinguishing  structural  peculiarity  of  an 
adenoma  is  the  presence  of  epithelium  disposed  as  in  a  secreting 
gland,  the  connective  tissue  (stroma)  entering  into  its  com- 
position must  also  be  taken  into  account.  In  many  adenomata 
the  epithelial  element  is  the  most  conspicuous  ;  in  others  the 
connective  tissue  is  out  of  all  proportion  to  the  epithelium, 
and  occasionally  preponderates  to  such  a  degree  that  the 
tumour  from  some  writers  receives  the  misleading  name  of 
"  adeno-sarcoma."     When    the    epithelium-lined    spaces    are 


ADENOMA    AND    CARCINOMA. 


219 


distended  witli   fluid   the  tumour   is  spoken  of  as  a  cystic 
adenoma  (adenocele). 

The  chief  species  of  adenomata  are  : — 

Mammaiy.  Renal. 

Sebaceous.  Ovarian. 

Thyroid.  Testicular. 

Pituitary.  Gastric. 

Prostatic.  Intestinal. 

Parotid.  Fallopian. 

Hepatic.  Uterine. 

Carcinomata   are    tumours  that  always   grow  from  pre- 
existing gland  tissue  and  mimic  the  parent  gland,  but  they 


V4^i 


Fig.  106. — Section  of  au  adenoma  from  a  child's  rectum.    {Highly  magnified.) 


differ  from  adenomata  in  the  fact  that  the  structural  mimicry 
is  incomplete ;  the  epithelial  cells,  instead  of  exhibiting  the 
regular  disposition  so  constant  in  those  tumours,  are,  in  the 
cancers,  collected  in  the  acini  and  ducts  in  irregular  clusters, 
or  fill  them  so  completely  as  to  give  rise  to  the  appearance  of 


220  EFITHELIAL    TUMOUJIS. 

sections  of  coliiinns  of  epithelial  cells  when  seen  under  the 
microscope.     (Fig.  108.) 

As  in  the  case  of  adenomata,  there  are  species  of  carcino- 
mata  depending  upon  the  relation  of  the  epithelium  to  the 
stroma  of  the  tumour.  Each  of  these  will  be  considered  when 
the  various  species  are  described.  Carcinomata  arise  in  every  - 
secreting  gland  that  gives  rise  to  an  adenoma ;  but  they  are 
very  common  in  some  glands  and  exceedingly  rare  in  others  ; 
indeed,  those  glands  which  are  the  most  frequently  affected 
with  adenoma  are  the  most  liable  to  carcinoma,  with  the 
exception  of  the  ovar}^     The  chief  species  of  carcinoma  are  : — 

Mammary.  Renal. 

Sebaceous.  Ovarian. 

Thyroid.  Testicular. 

Prostatic.  Gastric. 

Parotid.  Intestinal. 

Pancreatic.  Fallopian. 

Hepatic.  Uterine. 

Cancers  are  not  encapsuled,  but  infiltrate  surrounding 
tissues  and  pass  beyond  the  glands  in  which  they  originate ; 
they  are  very  prone  to  involve  the  superficial  tissues,  ulcerate, 
and  quickly  infect  the  lymph  glands  in  their  neighbourhood. 
A  marked  feature  of  carcinomata  is  their  great  tendency  to 
undergo  degenerate  changes  and  necrosis.  The  rapidity  with 
which  the  lymph  glands  are  infected  is  due  to  the  abundance 
of  lymphatics  in  most  species  of  cancer. 

Dissemination.  —  Cancers  are  exceptionally  prone  to 
become  disseminated  ;  the  secondary  growths  may  make  their 
appearance  in  any  organ  or  tissue,  and  not  infrequently  in  the 
bones.  The  cancer  germs  that  give  rise  to  these  secondary 
nodules  are  transported  by  lymph  and  blood-vessels,  and  when 
these  minute  emboli  are  lodged  in  suitable  situations  they 
multiply,  giving  rise  to  a  growth  which,  in  its  histological 
features,  exactly  resembles  the  parent  tumour.  So  faithful  is 
this  reproduction  that  the  nature  of  the  primary  tumour  can 
often  be  correctly  inferred  from  a  microscopic  examination  of  a 
secondary  nodule. 

The  amount  of  dissemination  varies  greatly.  In  some  cases 
secondary  deposits  will  be  found  only  in  the  liver,  whilst  in 


ADENOMA    AND    CABGINOMA.  221 

another  and  apparently  identical  case,  in  so  far  as  the  structure 
of  the  tumour  is  concerned,  secondary  knots  occur  in  almost 
every  organ  of  the  body,  including  the  skeleton. 

Secondary  deposits  of  cancers  are  not  always  so  small  as 
merely  to  merit  the  name  of  knots,  but  form  occasionally 
tumours  of  some  magnitude,  and  may  even  excel  in  size  the 
primary  tumour. 

MAMMARY   ADENOMA   AND   CARCINOMA. 

Adenomata. — There  are  two  varieties  of  mammary  ade- 
noma : — 1,  Fihro-adenoma ;  2,   Cystic  adenoma  (adenocele). 

1.  Fibro-adenomata  occur  as  spherical  or  oval  tumours, 
furnished  Avith  distinct  capsules,  lodged  in  the  superficial  parts 
of  mammae ;  exceptionally  the}'  may  be  situated  deeply  in  the 
breast  substance.  As  a  rule,  they  are  firm  and  elastic  to  the 
touch,  and  slip  about  under  the  examining  finger.  It  is  not 
rare  to  find  a  fibro-adenoma  in  each  manuna,  but  it  is  unusual 
to  find  more  than  one  tumour  in  the  same  gland.  When 
occupying  a  superficial  position  they  will,  even  when  small, 
project  the  skin  so  as  to  cause  an  irregularity  in  the  contour  of- 
the  breast ;  very  exceptionally  they  may  be  pedunculated. 
Although  the  majority  of  mammary  adenomata  do  not  exceed 
the  dimensions  of  a  walnut  or  a  Tangerine  orange,  some  are 
as  big  as  cocoa-nuts. 

Structurally  they  consist  of  fibrous  tissue  in  which 
glandular  acini  are  embedded ;  the  tumour  itself  is  isolated 
from  the  surrounding  gland  tissue  by  a  thick  capsule. 

2.  Cystic  Adenomata. — These  tumours  often  attain  a  very 
large  size,  and  specimens  now  and  then  come  under  observa- 
tion weighing  ten  or  twelve  pounds.  Like  fibro-adenomata 
they  are  encapsuled,  and  have  a  fibrous  stroma  with  glandular 
acini  embedded  therein;  but  the  acini  are  dilated  so  as  to  form 
epithelium-lined  cavities,  from  the  walls  of  which  papilloma- 
tous processes  project  and  form  what  are  known  as  intracystic 
growths.  The  size  and  number  of  the  cavities  and  the  amount 
of  intracystic  growth  vary  greatly  in  different  cases.  This 
variety  of  adenoma  grows  slowly,  and  produces  very  little 
disturbance  of  the  health ;  by  pressure  it  induces  atrophy  of 
the  true  gland  tissue,  which  in  some  cases  becomes  reduced 
to  exceedingly  small  proportions. 

Adenomata  occur  at  any  age  from  puberty  to  the  fiftieth 


222  EPITHELIAL    TUMOURS. 

year — that  is,  daring  the  period  of  sexual  activity.  Filjro- 
adenoinata  are  most  common  between  the  ages  of  twenty  and 
thirty,  whereas  the  cystic  adenomata  are  most  common  after 
the  thirtieth  year.  The  small  tibro-adenomata  are  frequently 
sources  of  pain  and  inconvenience,  especially  during  menstrua- 
tion. Most  patients  experience  pain  and  discomfort  when  the 
tumour  is  handled.  Both  varieties  of  mammary  adenomata 
occasionally  occur  in  young  men. 

Cystic  adenomata  are  rarely  a  source  of  pain,  but  they  may 
become  inconvenient  when  very  large.  In  a  case  under  the 
care  of  Stanley  the  patient  had  had  a  tumour  of  the  breast 
twelve  years.  It  gradually  became  pendulous,  and  when  she 
sat  the  breast  rested  in  her  lap.  At  last  the  integument 
sloughed;  the  breast  was  then  removed  by  cutting  through  the 
pedicle. 

It  is  not  uncommon  to  find  in  the  breasts  of  unmarried 
women  between  the  twenty-fifth  and  the  thirty-fifth  years, 
small  rounded  bodies  that  are  extremely  painful  when 
pressed.  These  often  convey  to  the  finger  an  impression  similar 
to  that  imparted  by  a  small  fibroma.  They  are  most  common 
around  the  periphery  of  the  areola,  but  they  occur  in  all  parts 
of  the  breast.  When  dissected  out  they  have  a  corymbose 
appearance,  and  are  composed  of  tiny  cysts  continuous  with 
the  mammary  tissue.  They  are  often  a  source  of  distress  to 
nervous  women  ;  otherwise  they  are  of  no  importance. 

Carcinomata. — There  are  two  varieties  of  mammary  cancer 
— namely,  acinous  cancer  and  duct  cancer. 

1.  Acinous  Carcinoma. — This  variety  presents  much  histo- 
logical diversity,  which  has  led  to  great  confusion  in  surgical 
writings.  In  the  most  typical  form  it  occurs  as  a  solitary  hard 
tumour  (so  hard  as  to  obtain  the  name  of  scirrhous  cancer) 
situated  at  the  base  of  the  nipple ;  but  it  may  occur  at  any  part 
of  the  gland,  even  at  its  periphery.  When  the  tumour  is  near 
the  areola  it  will  often  induce  retraction  of  the  nipple ;  when 
situated  in  other  parts  of  the  breast  it  will  lead  to  dimpling 
and  puckering  of  the  overlying  skin. 

On  section  such  a  tumour  has  the  appearance  and  consist- 
ence of  an  unripe  pear ;  microscopically,  it  will  be  found  to  con- 
sist of  columns  of  epithelial  cells,  disposed  like  the  lobules  of 
the  gland,  embedded  in  dense  fibrous  tissue.     The  tumour  has 


EPITHELIOMA. 


223 


no  capsule,  and  fades  away  indefinitely  into  the  surrounding 
tissues.  Wlien  .the  parts  beyond  the  tumour  are  examined, 
isolated  collections  of  cells  will  often  be  detected. 


Fig.  107. — Cancer  of  the  breast ;  the  clotted  line  indicates  the  extent  to  which  tlie 
nipple  and  areola  have  retracted. 

In  other  cases  the  tumour  will  be  only  moderately  firm, 
and  on  section  exhibit  a  succulent  appearance.  When  micro- 
scopically examined  it  presents  alveolar  spaces  lined  with 
epithelium,  here  and  there  raised  into  irregularly-shaped 
heaps.  Such  cases  are  difiicult  to  distinguish  from 
adenomata ;  but  when  the  sections  are  attentively  examined, 
parts  will  be  found  in  which  the  alveoli  are  completely  filled 
with  irregularly-shaped  epithelial  cells. 

In  many  examples  of  mammary  cancer  the  tumour,  when 
bisected,  appears  to  the   naked  eye  merely  like  a  tract  of 


224  EPITHELIAL    TUMOUUH. 

cicatricial  tissue,  and  feels  as  hard  as  cartilage  ;  when  examined 
microscopically  it  will  be  found  to  consist  of  strands  of  fibrous 
tissue  enclosing  here  and  there  a  few  epithelial  cells.  This 
variety  is  sometimes  spoken  of  as  "  withering  "  or  contracting 
scirrhus  ;  it  runs  a  much  slower  course  than  the  preceding 
kinds,  and  gradually,  by  its  contraction,  causes  the  gland  to 
shrivel,  so  that  at  length  the  patient  presents  an  appear- 
ance as  if  the  breast  had  been  removed.  Some  of  these 
cases  have  been  known  to  last  ten  and  even  fifteen  years. 


3-M 
Fig.  108. — Section  from  a  mammary  cancer.     {Highly  magnified.) 

Clinical  Features. — Acinous  cancer  of  the  breast  never 
develops  before  puberty,  and  is  very  rare  before  the  age  of 
thirty ;  it  is  most  common  between  forty  and  fifty ;  after  fifty 
it  gradually  becomes  less  frequent,  and  is  rare  after  seventy. 
I  have  seen  it  in  a  woman  ninety  years  of  age. 

This  variety  of  breast  cancer  occurs  in  the  single  as  well  as 
the  married ;  in  the  sterile  as  well  as  in  those  who  have  had 
many  children  :  in  women  who  have  nursed  their  offspring  and 
in  those  who  have  never  o-iven  suck.     It  also  attacks  the  male 


ADENOMA   AND   CARCINOMA.  225 

breast.  Mammary  cancer  is  one  himclred  times  more  frequent 
in  women  than  in  men. 

It  usually  attracts  attention  as  a  circumscribed  liard  lump 
in  tbe  mamma ;  it  never  forms  a  large  tumour — indeed  a 
mammary  cancer  rarely  exceeds  the  dimensions  of  a  fist.  The 
rate  of  growth  may  be  slow,  often  extremely  slow,  especially 
in  old  individuals.  When  cancer  appears  during  lactation  it 
progresses  with  frightful  rapidity. 

As  the  tumour  increases  in  size  it  infiltrates  surrounding 
tissues,  becomes  adherent  to  the  fascia  of  the  pectoral  muscle, 
and  even  infiltrates  the  muscle  ;  at  the  same  time  it  implicates 
the  subcutaneous  tissue.  These  infiltrated  tissues  shrink  and 
cause  the  cancerous  breast  to  become  smaller,  often  much 
smaller,  than  its  fellow.  This  fact  is  illustrated  by  Fig.  107. 
The  general  shrinking  of  the  breast  is  an  important  factor  in 
diagnosis,  and  must  not  be  confounded  with  retraction  of  the 
nipple,  which  is  of  no  diagnostic  import,  as  it  occurs  under  a 
variety  of  conditions. 

Lymph  gland  infection  occurs  early  in  cancer,  and  is  an 
important  clinical  sign.  The  glands  of  the  axilla  which  run 
parallel  with  the  free  border  of  the  greater  pectoral  are  first 
affected,  but  the  infection  quickly  extends  to  and  involves  the 
whole  set,  and  in  later  stages,  the  glands  lying  in  the  posterior 
triangle  of  the  neck  immediately  above  the  clavicle  enlarge. 

It  by  no  means  follows  that  because  a  tumour  of  the  breast 
is  unassociated  with  large  lymph  glands  the  tumour  is  not 
a  cancer.  By  the  time  the  glands  are  sensibly  enlarged  the 
tumour  has  made  its  way  towards  the  surface,  and  at  last  the 
skin  involved  in  the  growth  ulcerates.  The  advent  of  ulcera- 
tion is  heralded  by  a  purplish  or  bluish  appearance  of  the 
skin,  which  sometimes  resembles  a  recent  cicatrix  with  veins 
radiating  from  it,  or  the  surrounding  skin  may  be  dotted  with 
small  knots  of  the  size  of  a  split  pea  or  even  larger. 

After  the  skin  breaks,  the  ulcer  tends  to  spread,  and  soon 
assumes  the  typical  appearance  of  a  cancerous  ulcer ;  its 
edges  are  raised  and  rampart-like,  and  surround  an  irregular 
depression,  the  floor  of  which  is  formed  of  firm  granulations, 
discharging  a  foul  ichorous  or  blood-stained  fluid.* 

*  T.  W.  Nunn,  in  his  work,  "  On  Cancer  of  the  Breast,"  London,  1882,  gives 
some  admirable  and  life-like  illustrations  of  the  various  stages  of  mammary  cancer. 

P 


226  EPITHEIjIAL   TUMOUIiS. 

Pain. — There  is  no  syiiiptoin  more  varialjle  in  nianmiary 
cancer  than  pain.  A  large  proportion  of  patients  experience 
no  painful  sensations  whatever,  and  are  absolutely  ignorant  of 
the  presence  of  any  disease  in  the  breast  until  their  attention 
is  arrested  by  some  irregularity  in  its  outline,  or  some  marked 
difference  in  the  comparative  size  of  the  two  breasts,  or  it  is 
accidentally  observed  by  a  friend.  In  others  the  pain  is  so 
severe  that  the  patients  suffer  torture  so  intense  that  only  the 
imagination  can  suggest  parallels.  In  some  the  pain  is 
localised,  but  in  others  it  radiates  from  the  tumour  to  the 
surrounding  parts.  Pathology  has  totally  failed  to  furnish  an 
explanation  why,  in  two  patients  of  about  the  same  age, 
temperament,  and  character,  each  having  a  tumour  in  the 
breast  in  corresponding  situations,  and  in  structure  identical, 
one  should  suffer  anguish  too  terrible  to  describe,  and  the 
other  be  absolutely  free  from  pain,  and  often  devoid  even  of 
any  feeling  of  discomfort. 

Concurrently  with,  but  more  frequently  subsequent  to, 
infection  of  the  lymph  glands  secondary  deposits  occur  in  the 
viscera,  especially  the  liver  and  lung ;  but  any  organ  may  be 
the  seat  of  deposit. 

When  the  liver  is  attacked  it  enlarges,  and  there  may  be 
hydroperitoneum,  rarely  jaundice  ;  deposits  in  the  lungs  and 
pleurae  set  wp  pneumonia  and  pleurisy.  When  effusions  occur 
in  the  pleurae,  peritoneum,  or  pericardium,  as  a  result  of 
cancerous  infection,  the  fluid  is  often  blood-stained. 

Secondary  deposits  in  the  brain  give  rise  to  mental  aliena- 
tion and  coma.  Deposits  in  the  bones  cause  "  spontaneous  " 
fracture,  and  when  the  vertebral  column  is  implicated  para- 
plegia preceded  by  acute  suffering  is  the  usual  consequence. 
Enlarged  glands  and  secondary  deposits  may  so  involve  large 
vessels  and  lymphatic  trunks  in  the  axilla  as  to  produce  solid 
oedema  of  the  arm. 

It  must  also  be  remembered  that  in  the  late  stages  of  the 
disease  the  tissues  covering  the  thorax  may  be  infiltrated,  and 
this  local  extension  may  implicate  the  ribs  and  directly  infect 
the  pleura. 

One  of  the  rarer  effects  of  secondary  deposits  is  when  they 
break  out  in  a  great  number  of  small  knots  over  the  skin 
on  the  front  of  the  chest  and  both  breasts,  and  induce  such 


PLATE  v.— Cuirass  Cancer.  The  Right  Breast  had  been  amputated 
two  years.  The  Right  Arm  is  in  the  condition  known  as 
"Lymphatic"  CEdema. 


ADENOMA  AND   GARGINOMA.  227 

induration  of  the  skin  that  it  becomes  so  rigid  as  to  resemble 
a  firm  leather  shield,  a  condition  which  has  earned  for  it  the 
name  of  "  cancer  en  ciiirasse."  In  this  extreme  condition 
the  skin  is  so  firm  and  hard  that  it  is  impossible  to  wrinkle 
it.  (Plate  V.)  This  peculiar  condition  is  probably  due  to 
cancerous  invasion  of  the  cutaneous  lymphatics. 

As  the  cancer  extends  locally  and  ulcerates,  and  more 
especially  when  there  is  evidence  of  secondary  deposits,  the 
patient's  health  begins  rapidly  to  decline  and  the  tissues  to 
waste.  It  is,  however,  astonishing  hoAv  women  with  breasts 
infiltrated  with  cancer,  or  eroded  by  large  and  foul  ulcers, 
will  sometimes  be  able  to  get  about  and  busy  themselves  with 
household  matters  :  and  this  state  of  things  will  continue  for 
many  months,  perhaps  until  the  supervention  of  pleurisy, 
pneumonia,  or  some  complication  due  to  the  dissemination  of 
the  cancer  incapacitates  them  and  extinguishes  life. 

Lymphatic  (Edema.  —  This  occasional  compUcation  of 
mammary  cancer  must  be  considered  on  account  of  the  in- 
convenience and  distress  it  produces.  It  is  a  condition  which 
cannot  be  mistaken.  The  oedema  usually  becomes  manifest 
in  the  skin  about  the  shoulder,  and  gradually  extends  to  the 
skin  of  the  arm,  and  in  due  course  involves  the  forearm  and 
hand ;  the  skin  covering  the  scapula  is  also  implicated.  The 
limb  in  typical  cases  has  a  swollen  appearance  as  though 
anasarcous,  but  when  the  skin  is  pressed,  instead  of  pitting  on 
pressure  it  will  be  found  firm,  brawny,  and  unyielding. 

The  limb  grows  extremely  heavy,  and  the  patient  finds  it 
necessary  to  support  it  in  a  sling ;  exceptionally  the  weight  of 
the  limb  prevents  the  patient  from  taking  walking  exercise, 
and  usually  produces  a  moderate  degree  of  lateral  curvature 
of  the  spine.  The  connective  tissue  may  be  so  infiltrated 
with  lymph  that  the  skin  becomes  so  tense  as  to  prevent 
movement  at  the  wrist,  elbow,  and  shoulder ;  under  such 
conditions  the  arm  resembles  a  cast  rather  than  a  living  limb, 
and  is  absolutely  useless. 

When  the  tissues  of  such  a  limb  are  examined  immediately 
after  death,  it  will  be  noticed  that  the  increase  in  size  is  due 
to  infiltration  of  the  subcutaneous  tissue  with  lymph,  which 
causes  the  cut  surface  to  resemble  in  colour  and  in  texture 
the  pulp  of  a  succulent  orange,  and  large  quantities  of  lymph 


228  EPITHELIAL    TUMOURS. 

fiow  from  the  incisions.  The  muscles  are  smaller  than  natural 
and  infiltrated  with  fat.  In  the  character  of  the  fluid  which 
exudes  from  the  limb,  and  the  firmness  of  the  infiltrated 
connective  tissue,  it  resembles  the  oedema  characteristic  of 
myxoedema. 

In  the  condition  we  are  considering,  the  obstruction  to  the 
lymphatic  circulation  of  the  upper  limb  is  due  to  the  pressure 
of  lymph  glands  infiltrated  with  cancer,  or  to  secondary 
nodules  lying  in  the  course  of  the  main  lymphatic  channels 
at  the  apex  of  the  axilla.  Exceptionally  it  complicates  the 
rare  form  of  cancerous  dissemination  known  as  cuirass  cancer. 

Lymphatic  oedema  of  the  upper  limb  may  suj)ervene  in 
patients  with  cancerous  breasts  who  have  never  been  sub- 
mitted to  operation,  in  those  in  which  the  axillary  lymph 
glands  were  removed  when  the  breasts  were  amputated,  and  in 
those  whose  axillte  were  not  interfered  with.  Many  more 
cases  have  come  under  ray  notice  in  the  right  than  in  the  left 
arm.  Pain  is  experienced  in  the  limb  by  most  of  the  patients, 
and  it  is  often  very  severe.  This  is  due  not  to  the  oedema,  but 
to  the  enlarged  glands  or  cancerous  nodules  pressing  on  the 
cords  of  the  brachial  plexus  or  their  branches. 

2.  Duct  Carcinoma. — Towards  the  approach  of  the  meno- 
pause the  breast  enters  into  a  resting  stage ;  its  glandular 
structures  atrophy,  and  nothing  but  ducts  remains. 

Breasts  in  this  condition  often  present  on  their  deep 
surfaces  large  numbers  of  cysts  varying  in  size  from  a  mustard 
seed  to  a  cherry.  These  are  often  called  involution  cysts,  and 
are  filled  with  mucoid  fluid  which  causes  them  to  assume 
a  bluish  tint  when  the  breast  is  examined  after  its  removal 
from  the  body.  The  cysts  are  most  abundant  on  the  deep 
surface  of  the  gland. 

Cystic  breasts  of  this  kind  are  most  frequently  met  with 
between  the  forty-fifth  and  fifty-fifth  years.  In  sterile  women 
they  occur  somewhat  earlier,  and  as  a  rule,  both  breasts  are 
affected.  When  cystic  disease  of  this  kind  is  more  advanced 
in  one  breast  than  the  other,  it  is  apt  to  be  mistaken  for 
diffuse  cancer.  It  is  quite  exceptional  for  this  variety  of 
cystic  disease  to  give  rise  to  pain.  Cystic  mammary  glands 
of  this  character  require  attentive  study  because  the  walls  of 
the  dilated  ducts  are  occasionally  the  starting-p  oints  of  cancer. 


ADENOMA  AND   OARGINOMA.  229 

In  rare  instances  villous  processes,  or  papillomata,  sprout  from 
the  walls  of  such  C3^sts,  particularly  when  the  cysts  represent 
dilated  lacteal  sinuses. 

When  cancer  arises  in  dilated  mammary  ducts  it  is  now 
customary  to  speak  of  it  as  duct  cancer.  This  variety  occurs 
most  frequently  in  the  terminal  ducts  and  especially  in  the 
ampullae  (lacteal  sinuses),  usually  as  a  smgie  tumour  ;  occasion- 
ally several  isolated  nodules  are  present  in  the  same  gland.  The 
tumour  is  in  some  cases  no  larger  than  a  walnut,  but  may  be 
as  big  as  a  child's  fist.  When  situated  near  the  skin  it  assumes 
a  deep  red  or  even  purple  colour. 

Seen  in  section,  the  cancer  will  be  found  provided  with  a 
distinct  capsule  (the  dilated  duct),  whilst  the  mass  withm 
projects  as  a  soft  red  outgrowth  from  the  cyst-wall;  some- 
times this  is  so  large  as  completely  to  occupy  the  cavity. 
When  this  intracystic  growth  is  examined  microscopically  it 
will  be  found  to  consist  of  glandular  spaces  lined  with  regular 
columnar  or  subcolumnar  epithelium.  Sometimes  the  intra- 
cj^stic  mass  takes  the  form  of  villous  processes,  like  those 
sometimes  met  with  in  the  bladder.  Such  are  termed  duct 
papillomata  of  the  mamma.     (Fig.  89). 

Clinical  Features. — Duct  papilloma  and  duct  cancer  ap- 
pear most  frequently  between  the  age  of  thirty-five  and 
sixty-five.  The  tumour  is  always  softer  than  in  the  common, 
or  acinous,  variety.  When  seated  near  the  skin  it  assumes  a 
dark-red  or  even  purple  tint,  and  has  even  been  mistaken  for 
a  melanoma.  The  nipple  is  not  retracted,  but  may  be  in- 
verted. This  is,  however,  a  sign  of  no  value.  In  a  very  large 
proportion  of  cases  there  is  an  abundant  discharge  of  blood- 
stained fluid  from  the  nipple.  The  tumour  grows  very  slowly, 
rarely  implicates  the  lymph  glands,  and  exhibits  very  little 
tendency  to  recur  or  to  become  disseminated.  It  is  the  least 
malignant  variety  of  mammary  cancer. 

Literature. — The  best  reported  cases  of  duct  cancer  will 
be  found  in  the  Trans.  Path.  Soc,  vols,  xxxvii.,  xxxviii., 
xxxix.,  xl.,  and  xli.  See  also  Bowlby,  St.  Barth.  Hosp.  Rep., 
vol.  xxiv.,  263. 

Treatment. — The  removal  of  a  fibro-adenoma  of  the 
mamma  is  such  a  simple  proceeding  and  so  devoid  of  risk 
that  it  is  the  mode  of  treatment  almost  exclusively  employed 


230  EPITHELIAL   TUMOURS. 

against  these  tumours.  Even  large  cystic  adenomata  (adeno- 
celes)  weighing  eight  or  ten  pounds  may  be  removed  with 
marvellously  little  risk  to  the  patients,  and  recovery  is  in- 
variably rapid  and  complete. 

The  treatment  which,  with  our  present  knowledge,  offers 
the  best  prospect  to  individuals  affected  with  mammary 
cancer  is  early  and  convplete  removal  of  the  whole  of  the 
diseased  gland  and  pectoral  fascia. 

Careful  observations  show  clearly  enough  that  those 
patients  do  best  who  have  the  cancerous  mammae  extirpated 
at  the  earliest  possible  date  after  the  tumour  is  perceived. 
There  is  a  consensus  of  opinion  among  surgeons  who  have 
had  the  largest  experience  in  cancer  that,  when  a  patient 
comes  under  observation  with  a  nodule  in  the  mamma  which 
it  is  reasonable  to  regard  as  cancerous,  it  is  the  duty  of  the 
medical  attendant  to  advise  the  removal  of  the  breast.  It  is, 
however,  a  remarkable  fact  that  mammary  tumours,  innocent 
and  malignant,  have  been  subject  to  observation  for 
centuries,  yet  there  is  no  organ  in  the  body  in  which  tumours 
give  rise  to  more  doubt  or  diiiiculty  in  diagnosis  than  in  the 
mamma.  This  is  so  generally  recognised  that  it  is  the  duty 
of  every  surgeon,  before  amputating  a  breast,  to  make  an 
incision  into  the  swelling  in  order  to  assure  himself  that  he  is 
really  dealing  with  a  malignant  tumour  and  not  a  simple 
cyst,  abscess,  or  localised  inflammation.  The  chief  difliculty 
the  surgeon  finds  in  recommending  appropriate  treatment  for 
cancer  of  the  breast,  arises  from  the  circumstance  that  patients 
so  often  conceal  the  fact  that  they  have  a  tumour  until  com- 
pelled to  seek  advice  on  account  of  pain,  discomfort,  or  actual 
misery  induced  by  the  ulceration  and  sloughing  of  the  cancer. 
There  is,  of  course,  a  small  proportion  of  females  who  absolutely 
refuse  to  submit  to  operation  in  the  early  hopeful  stages,  and 
wait  until  the  skin  becomes  involved  before  they  realise 
their  unfortunate  condition.  When  the  tumour  has  been 
allowed  to  run  its  course  and  infect  the  axillary  lymph  glands 
or  ulcerate,  the  chance  of  doing  good  by  operation  is 
seriously  diminished. 

The  prospects  of  a  patient  with  cancer  of  the  breast,  when 
submitted  to  operation  may  be  indicated  in  the  following 
manner  : — 


ADENOMA  AND   GAUCINOMA.  231 

1.  The  cancer  is  limited  to  the  breast,  does  not  iniphcate 

the  skin  or  pectoral  muscle,  and  has  not  induced  ap- 
preciable enlargement  of  the  axillar}'-  lymph  glands. 
Such  a  case  gives  good  results,  immediate  and  remote. 
The  risks  of  the  operation  are  very  small  (one  per  cent.),  and 
as  there  is  no  interference  with  the  axilla,  the  patient  retains 
free  use  of  the  arm.  Recurrence  and  dissemination  may  be 
indefinitely  delayed. 

2.  The  cancer  implicates  the  skin,  but  has  not  yet  ulcerated : 

moderate  enlargement  of  lymph  glands. 
Immediate  extirpation  of  the  breast,  cutting  wide  of  the 
implicated  area  of  skin,  dissecting  away  the  pectoral  fascia, 
and  removal  of  the  axillary  lymph  glands  is  the  proper  course. 
Many  of  these  patients  enjoy  a  long  immunity  from  recurrence, 
but  their  expectancy  of  life  is  less  than  in  the  preceding  class. 
The  immediate  risk  to  life  is  much  greater  in  consequence  of 
the  interference  with  the  armpit. 

3.  The  cancer  has  ulcerated,  but  the  extent  of  skin  impli- 

cated is  small ;  there  is  no  adhesion  of  the  tumour  to  the 
chest  wall.     The  axillary  lymph  glands  are  enlarged. 

In  such  a  case  many  surgeons  excise  the  breast  and  remove 
the  axillary  lymph  glands,  not  with  much  hope  of  prolonging 
life,  but  in  order  to  rid  the  patient  of  what  wdll  become  foul, 
offensive,  and  a  source  of  mental  anofuish. 

Although  it  is  extremely  difficult  to  indicate  even  approxi- 
mate rules  as  to  the  advisability  or  otherwise,  of  operating 
in  certain  conditions  of  mammary  cancer,  there  are  cases  in 
which  it  can  be  definitely  laid  clown  that  operations  are 
useless.     For  instance  : — 

1.  When  the  supraclavicular  Ij^mph  glands  are  infected, 

whether  the  cancer  has  ulcerated  or  not ;  such  extensive 
infection  of  lymph  glands  indicates  a  high  degree  of 
malignancy. 

2.  When  a  large  area  of  skin  is  implicated,  and  particularly 

in  cases  where  it  is  brawny  or  beset  with  small  nodules. 
(Cuirass  cancer.) 

3.  In  the  withering  or  atrophic  form  of  cancer. 

4.  In  no  case  where  there  is  reason  to  believe  that  dis- 

semination has  occurred. 

5.  When  both  breasts  are  implicated. 


232  EFITIIELIAL   TUMOUliS. 

Of  all  the  circumstances  that  inodify  the  mortality  of 
operations  for  removal  of  the  mammary  gland,  none  influence 
it  so  much  as  opening  the  axilla.  This  proceeding  trans- 
forms a  simple  and  safe  operation  into  one  often  fraught 
with  danger.  So  important  is  this  that  I  will  emphasise 
again  my  opinions  in  regard  to  the  lymph  glands  : — 

1.  The  axilla  should  not  be  opened  unless  there  is  really  good 

reason  to  believe  that  its  lymph  glands  are  infected. 

2.  When  the  lymph  glands  are  obviously  enlarged  they 

should  be  removed  with  the  primary  tumour. 

3.  When  the  supraclavicular  lymph  glands  are  obviously 

infected,  operation  is  useless.  ' 

Not  only  does  the  removal  of  these  lymph  glands  increase 
the  risk  of  the  operation  and  impair  the  subsequent  utility  of 
the  limb,  but  in  operating  in  the  arm-pit  the  axillary  vein  has 
in  many  instances  been  torn  or  punctured.  Such  extensive 
proceedings  as  excision  of  large  portions  of  the  pectoral 
muscles,  and  division  of  the  clavicle  to  facilitate  the  removal  of 
outrunning  portions  of  the  tumours  are  hopeless  enterprises. 

Recurrence. — In  a  certain  proportion  of  cases  recurrence  of 
the  cancer  may  be  expected.  It  is  important  to  ascertain  on 
what  this  depends,  as  it  is  usually  regarded  as  an  indication 
that  the  disease  was  not  removed  at  the  time  of  operation. 
The  skin  incisions  may  have  been  made  too  near  the  tumour, 
or  fragments  of  the  glandular  tissue  may  have  been  detached 
and  left  behind  in  the  process  of  reflecting  the  skin ;  or  out- 
runners on  the  deep  surface  of  the  breast  may  have  been  cut 
across  and  small  pieces  remained  hidden  in  the  recesses  of  the 
wound.  All  these  have  been  advanced  to  explain  the  recurrence. 
The  reappearance  of  the  disease  may  take  the  form  of  one  or 
more  small  nodules  in,  or  near,  the  cicatrix  ;  sometimes  actually 
in  a  stitch-hole.  It  may  manifest  itself  as  a  brawn}^  infiltration 
of  the  skin  on  each  side  of  the  cicatrix,  and  exceptionally 
recurrence  appears  as  a  general  outburst  of  small  shotty 
nodules  in  the  skin  over  one  or  both  mammary  regions. 

When  the  recurrence  is  localised,  especially  in  the  form  of 
one  or  two  nodules,  or  even  as  a  tumour  the  size  of  an  egg,  it 
should  be  promptly  removed,  so  long  as  there  is  no  sign  of 
dissemination. 


233 


CHAPTER    XXIV. 

CYSTS,  ADENOMA  AND  CARCINOMA  OF  SEBACEOUS 
AND    MUCOUS    GLANDS. 

The  consideration  of  tumours  connected  with  sebaceous  glands 
naturally  follows  upon  that  of  tumours  of  the  mammary  gland, 
because  the  latter  is  regarded  as  being  a  highly  specialised 
sebaceous  gland  or  group  of  glands. 

It  will  also  be  necessary  to  deal  with  tumours  arising  in 
connection  with  the  cluster  of  specialised  sebaceous  glands  at 
the  base  of  the  glans  penis  known  as  Tyson's  glands,  for  they 
are  the  source  of  a  rare  species  of  penile  cancer. 

Tumours  connected  with  sebaceous  glands  are  :  —  1, 
Sebaceous  cysts  or  wens ;  2,  sebaceous  adenomata ;  3,  cancer  of 
Tyson's  glands. 

1.  Sebaceous  Cysts  (Wens). — The  sebum  resulting  from 
the  activity  of  a  sebaceous  gland  escapes  as  it  is  formed  on  to  the 
free  surface.  Should  the  orifice  of  the  follicle  become  occluded, 
the  secretion  is  retained,  and  the  glandular  acini,  becoming 
distended,  give  rise  to  an  appreciable  swelling  known  as  a 
sebaceous  cyst.  This  is  the  usual  description  of  the  mode  by 
which  these  cysts  arise  ;  but  even  a  superficial  examination  of 
a  number  of  sebaceous  cysts  will  serve  to  show  that  in  many 
there  is  no  obvious  obstruction — indeed,  the  duct  may  be 
widely  open  and  the  sebum  exuding,  so  that  obstruction  of  the 
duct  is  not  an  explanation  that  will  cover  all  cases. 

It  has  long  been  known  that  the  sebaceous  follicles  often 
contain  one  or  more  examples  of  the  demodex  folliculommi. 
It  is  usually  stated  that  these  arachnids  are  harmless ;  but 
judging  from  the  grave  lesions  one  species  of  clemodex  produces 
in  the  external  auditory  meatus  of  the  dog,  it  is  quite  open  to 
question  if  their  presence  is  merely  an  epiphenomenon. 

These  cysts  occur  in  all  situations  where  sebaceous  glands 
abound ;  an  exceptionally  common  place  is  the  scalp.  The 
cyst  may  be  single ;  sometimes  many  are  present — indeed  six- 
teen or  more  may  be  counted  on  one  scalp.  In  size  they  vary 
greatly  ;  many  are  as  large  as  walnuts  ;  others  are  of  the  size  of 
peas ;  they  are  rarely  bigger  than  Tangerine  oranges. 


234 


EFITIIEL  TAL   TUMO  URB. 


In  most  situations  sebaceous  cysts  are  readily  recognised, 
as  they  are  distinctly  circumscribed  and  adhere  to  the  skin. 
On  the  surface  of  sebaceous  cysts  occurring  in  any  part  of  the 
trunk  and  head,  save  the  scalp,  close  scrutiny  will  reveal  either 
a  black  dot  or  a  small  dimple.  This  is  the  orifice  of  the  follicle, 
and  on  picking  off  the  black  spot  and  squeezing  the  cyst, 
sebum  will  exude,  and  thus  furnish  positive  evidence  of  the 
nature  of  the  cyst.     It  is  a  curious  fact  that  in  wens  of  the 


Fig.  109. — Sebaceous  glands  in  the  velvet  of  the  antler  of  a  stag  {cervus  claplmis). 

scalp  the  orifice  is  rarely  seen,  except  those  which  occur  along 
the  junction  of  the  skin  of  the  forehead  with  the  hairy  scalp. 

A  sebaceous  cyst,  unless  it  has  been  inflamed,  is  easily 
shelled  out  of  its  matrix.  It  then  presents  a  capsule  and  con- 
tents. The  capsule  may  be  exceedingly  thin  and  pliant,  the 
inner  surface  presenting  an  epithelial  lining;  or  it  may  be 
laminated,  thick,  and  hard.  The  contents  of  the  cyst  may  be 
pultaceous  material,  consisting  of  shed  epithelial  scales,  fat  and 
cholesterine ;  or  lamina3  of  firm  yellowish-white  material 
arranged  like  the  tissue  of  a  bulb.  These  laminas  represent  the 
epithelium  of  the  lining  wall  that  has  been  shed  in  successive 
layers.  In  rare  instances  the  contents  of  sebaceous  cysts 
calcify.  Sebaceous  cysts  are  sometimes  mistaken  clinically  for 
dermoids,  and  vice  versa. 

Sebaceous  cysts  occur  not  only  in  the  scalp,  but  also  in  the 


PLATE  VI.— Inflamed  Sebaceous  Cyst,  situated  on  the  Inner  Margin  of 
the  Left  Mamma. 


ADENOMA   AND   CARCINOMA.  235 

skin  covering  any  part  of  the  trunk.  They  are  excessively 
rare  on  the  hmbs.  These  cysts  are  not  uncommon  in  the 
skin  of  the  penis  and  scrotum,  as  Avell  as  in  that  of  the  labia 
majora  and  minora.  Among  other  curious  situations  may 
be  mentioned  the  interior  of  ovarian  dermoids  and  in  the 
"  velvet  "  covering  the  growing  antlers  of  deer. 

The  "  velvet "  of  a  growing  antler  is  covered  with  fine 
downy  hair  furnished  with  large  sebaceous  glands.    (Fig.  109.) 

Sebaceous  cysts,  apart  from  the  inconvenience  their 
presence  often  causes,  and  their  unsightliness  w^hen  growing  in 
exposed  situations  become  sources  of  discomfort  when  their 
contents  decompose,  or  the  cyst  inflames.  Apart  from  this, 
they  are  liable  to  secondary  changes,  whereby  they  form 
peculiarly  foul  and  fungating  ulcers,  and  in  others  develop 
horns.     Each  of  these  changes  will  be  considered. 

Decomposition  of  the  Contents. — It  has  already  been  men- 
tioned that  the  contents  of  a  sebaceous  cyst  sometimes  ooze 
from  the  orifice  of  the  follicle.  In  some  instances  such  cysts 
give  rise  to  an  extremely  offensive  odour.  This  is  due  to  de- 
composition of  the  cyst-contents  in  consequence  of  admission 
of  air,  and  as  the  substance  within  the  cyst  contains  a  large 
proportion  of  fat  and  epithelium,  the  odour  evolved  is  not 
difiicult  of  explanation.  Decomposition  of  the  cyst-contents 
occurs  independently  of  inflammation  of  the  cyst,  and  is 
almost  confined  to  sebaceous  cysts  occurring  on  the  trunk. 

Inflammation  of  the  Cyst. — When  sebaceous  cysts  grow  in 
situations  Adhere  they  are  exposed  to  injury,  as,  for  instance,  on 
the  side  of  the  head,  where  they  may  be  injured  by  the  hat, 
or  on  parts  of  the  body  where  they  are  liable  to  be  rubbed 
by  the  clothes,  they  are  apt  to  inflame  and  suppurate.  An  in- 
flamed sebaceous  cyst  has  a  characteristic  colour,  and  re- 
sembles the  deep  red  of  a  ripe  plum.  (Plate  VI.)  Such 
inflammation  may  subside  and  recur.  These  recurrent  attacks 
of  inflammation  cause  firm  adhesion  between  the  capsule  and 
surrounding;"  structures,  which  renders  their  removal  somewhat 
tedious.  When  they  suppurate  the  cyst  thins,  and  at  last 
bursts,  unless  this  result  is  anticipated  by  the  timely  use  of  a 
scalpel.  The  suppuration  often  leads  to  their  cure ;  but  frag- 
ments of  capsule  may  be  retained  and  lead  to  the  formation  of 
fistulas.     In  some  instances  the  cyst  bursts,  the  pus  escapes, 


236 


EPi  THELIAL   T  UMO  UBS. 


and  the  point  of  rupture  heals,  the  cyst-wall  being  retained. 
When  this  is  the  case  the  cyst  refills  with  sebaceous  matter. 
Thus  in  dealing  with  these  cysts  surgically  it  is  an  important 
thing  to  remove  thoroughly  every  particle  of  the  cyst-wall. 

Horns. — Mention  has  already  been  made  of  the  fact  that 
sebaceous  cysts  are  occasionally  the  source  of  horns,  sometimes 
of  very  large  size.  In  their  general  appearance  and  structure 
they  are  indistinguishable  from  wart-horns.     {See  chap,  xx.) 

2.  Sebaceous  Adenomata. — It  has  been  so  customary  to 


■/w    ^'^'""^ 


Fig.  ]10. — Large  sebaceous  adenoma  invohing  the  pinna. 

regard  all  tumours  arising  in  connection  with  sebaceous  glands 
as  wens  or  sebaceous  cj^sts,  that  it  is  quite  an  exceptional  event 
for  them  to  be  submitted  to  microscopical  examination.  It 
has  already  been  pointed  out  that  there  are  two  varieties  of 
sebaceous  cysts,  one  in  which  the  cj'&t  contains  sebum  and 
epithelial  debris,  and  another  in  which  the  contents  are 
arranged  in  thick  laminae.  In  addition  to  these,  tumours 
occasionally  occur  in  the  skin  and  furnish  the  usual  clinical 
signs  of  wens  ;  *  when  removed  and  examined  microscopically 
they  are  found  to  be  comjDosed  of  lobules  which  structurally 

*  Shattock,  Trans.  Path.  Soc,  vol.  xxxiii.  290. 


ADENOMA   AND   GARCINOMA.  237 

resemble  the  exuberant  masses  upon  the  nose  that  used  to  be 
called  lipomata,  but  are  now  known  to  be  due  to  that  over- 
growth of  the  large  sebaceous  glands  that  occupy  the  skin 
in  this  situation.  These  tumours  are  sebaceous  adenomata, 
and  they  are  liable  to  ulcerate  and  exceptionally  to  calcify.* 
The  largest  sebaceous  adenoma  that  has  occurred  in  my 
own  practice  began  in  the  skin  over  the  mastoid  process  and 
involved  the  pinna.     (Fig.  110.)  t 

There  can  be  little  doubt  that  a  few  of  the  supposed  wens 
on  the  scalp  are  adenomata,  especially  those  which  fungate. 
These  supposed  fungating  wens  should  be  carefully  studied ; 
they  are  particularly  apt  to  be  mistaken  for  epitheliomata. 
Such  tumours  consist  of  more  or  less  circular  masses  of  red 
vascular  tissue  with  definite  edges,  raised  a  centimetre  or  more 
above  the  level  of  the  surrounding  skin,  and  strikingly  resemble 
ulcerating  epitheliomata  —  a  resemblance  that  is  rendered 
more  complete  when  the  adjacent  lymph  glands  are  enlarged. 
The  discharge  from  such  tumours  is  always  very  foetid. 

There  is  usually  no  difficulty  in  recognising  the  nature  of 
these  masses  when  they  occur  on  the  scalp,  as  they  are  not 
infrequently  associated  with  wens.  {Frontispiece.)  These  ap- 
pearances are  usually  described  as  the  result  of  inflammation 
and  subsequent  rupture  of  a  sebaceous  cyst.  This  is  probably 
the  correct  explanation  in  some  cases,  but  in  others  the 
tumour  is  made  up  of  adenomatous  tissue,  which  makes  it 
certain  that,  in  a  few  instances  at  least,  the  supposed  fungating 
cyst  is  an  ulcerating  sebaceous  adenoma. 

3.  Carcinoma. — The  common  variety  of  sebaceous  glands 
•  is  not  the  source  of  any  species  of  cancer.  There  is,  however, 
a  rare  species  of  cancer  constructed  on  the  type  of  the 
specialised  sebaceous  glands  named  after  Tj^son.  I  once  had 
an  opportunity  of  studying  such  a  tumour  in  a  man  fifty 
years  of  age ;  it  sprang  from  the  penis  and  was  confined  to 
the  corona  glandis  and  adjacent  parts  of  the  penis.  The 
lymph  glands  in  each  groin  were  infected.  I  amputated  the 
penis  and  enucleated  the  enlarged  lymph  glands.  The 
patient  died  nine  months  later  with  the  signs  of  secondary 
deposits   in   the   abdominal   viscera,   but   no    dissection   was 

*  Eve,  Trans.  Path.  Soc,  vol.  xxxiii.  335. 
t  Trans.  Clin.  Soc,  vol.  xxi.  172. 


238  EPITHELIAL   TUMOURS. 

permitted.  Sections  were  prepared  from  the  tumour  in  such  a 
w&j  as  to  inchide  the  glans  penis,  its  corona,  and  the  tumour ; 
in  this  way  the  relation  of  the  cancer  to  Tyson's  glands  was 
clearly  demonstrated. 

Treatment. — A  sebaceous  cyst  is  easily  removed  ;  when 
the  skin  covering  one  is  incised  and  the  capsule  exposed, 
the  cyst  usually  shells  out  quite  easily.  When  the  cyst  has 
been  inflamed  and  is  firml}^  adherent  to  the  skin,  some  little 
dissection  will  be  necessary  to  effect  its  removal. 

A  suppurating  cyst  can  in  many  instances  be  dissected 
out.  Often,  however,  the  wall  is  so  thin  that  the  cj^st  is  best 
treated  as  an  abscess — that  is,  by  free  incision. 

Before  the  importance  of  extreme  cleanliness  was  appre- 
ciated by  surgeons  the  removal  of  sebaceous  cysts  was  often 
followed  by  septic  inflammation.  An  excellent  notion  of  the 
fears  which  surgeons  entertained  in  regard  to  secondary  com- 
plications after  the  removal  of  wens  is  furnished  by  the  case 
of  George  IV.,  who  had  a  sebaceous  cyst  on  the  top  of  his  head. 
This  formed  the  subject  of  a  serious  consultation  attended 
by  Cline,  Astley  Cooper,  Brociie,  and  others.  Eventually 
Cooper,  with  Cline's  assistance,  removed  the  wen,  and  his 
anxiety  lest  erysipelas  should  supervene  seems  scarcely  com- 
pensated by  the  baronetc}^  which  the  king  bestowed  upon  him 
as  a  reward  for  the  successful  issue  of  the  operation.* 

Mucous  Glands. — These  structures,  like  sebaceous  glands, 
sometimes  become  transformed  into  cysts,  but  they  rarely 
exceed  the  dimensions  of  a  nut ;  usually  they  appear  as  small 
transparent  bodies  the  size  of  small  peas.  They  are  fairly 
frequent  in  the  buccal  mucous  membrane  ;  they  also  occur  in 
the  mucous  membrane  lining  the  trachea  and  bronchi.  {See 
tracheal  diverticula). 

The  mucous  srlands  of  the  bronchi  are  of  interest  in  con- 
nection  with  reported  cases  of  supposed  primary  cancer  of  the 
lung.     For  instance,  Dr.  Finlayf  described  the  case  of  a  man 


*  "  Life  of  Sir  Astley  Cooper,"  vol.  ii.,  chap.  ix.  Brodie  refers  to  this  case  in 
his  "  Autobiography,"  thus  : — "  Eventually  the  operation  was  performed  hy  Sir 
Astley  Cooper  in  the  presence  of  Sir  Everard  Home,  Mr.  Cline,  Sir  William 
Knighton,  the  King's  physicians,  Sir  Henry  Halford,  Sir  Matthew  Tierney,  and 
myself  ;  making  a  very  large  assembly  for  so  small  a  matter." 

t  Med.-Chir.  Trans.,  vol.  Ix.  313. 


ADENOMA   AND   CARCINOMA.  239 

thirty-seven  years  old  who  died  from  pulmonary  disease. 
The  left  lung  contained  a  tumour  and  the  right  one  numerous 
secondary  nodules ;  some  of  the  mediastinal  lymph  glands 
were  enlarged  and  the  liver  contained  secondary  nodules. 
These  tumours  exhibited  the  characteristic  histological  features 
of  cancer.  Coats*  reported  a  case  which  he  investigated  in  a 
youth  seventeen  years  old  who  died  from  a  tumour  of  the 
right  lung.  There  were  secondary  nodules  in  the  left  lung, 
the  brain,  the  femora,  some  of  the  ribs,  vertebrse,  left  ilium, 
and  the  liver.  Many  of  the  secondary  knots  were  small  cysts 
lined  with  cylindrical  epithelium. 

Langhans,t  who  appears  to  have  studied  tumours  of  this 
kind  very  carefully,  is  of  ojiinion  that  the  cancer  in  such  cases 
originates  in  the  mucous  glands  of  the  bronchi. 

The  Glands  of  Bartholin  and  Cowper. — It  is  well  known 
that  Bartholin's  glands  in  the  female  are  very  liable  to  become 
cystic  ;  they  are  also  very  apt  to  inflame  and  suppurate.  These 
glands  are  occasionally  the  source  of  carcinoma.  Schweizer  J 
has  reported  a  case,  and  collected  the  literature. 

Cowper's  Glands  are  the  homologue  in  the  male  of 
Bartholin's  glands  in  the  female.  They  are  liable  to  inflame, 
and  occasionally  become  cystic.  There  is  reason  to  believe 
that  the  gland  may  become  cancerous.  The  most  recent 
contribution  to  this  subject  is  that  by  Witsenhausen.il 

Treatment. — Inflamed  Bartholin  glands  are  sources  of 
much  inconvenience  and  often  distress,  which  mere  incision 
only  serves  to  aggravate.  The  appropriate  treatment  consists 
in  dissecting  out  every  trace  of  the  gland. 

*  Trans.  Path.  Soc,  vol.  xxxix.  326. 
f  Yirchow's  "  Archiv,"  vol.  liii.  470. 
X  Arch,  fiir  Gyn.  hd.  xliv.  322. 
II  Bruns,  Beitrage,  bd.  vii.  582. 


240 


CHAPTER    XXV. 

ADENOMA    AND    CARCINOMA    OF    THE    THYROID, 
PROSTATE,    PAROTID   AND    PANCREAS. 

THE   THYROID   GLAND. 

Adenomata. — Two  varieties  of  adenoma  are  met  with  in  the 
thyroid  gland ;  by  most  writers  they  are  described  as  adeno- 
matous goitre  and  cystic  goitre  or  bronchocele,  to  distinguish 
them  from  the  general  enlargement  of  the  entire  gland  known 
as  "  parenchymatous  "  goitre.  A  thyroid  adenoma  is  an  encap- 
suled  tumour  of  the  thyroid  gland  containing  vesicles  of  the 
same  character  as  those  which  make  up  the  normal  gland. 
The  size  of  these  adenomata  varies  greatly ;  many  are  no  larger 
than  cherries,  whilst  others  are  bigger  than  fowls'  eggs.  When 
both  lobes  contain  an  adenoma  the  gland  will  maintain  its 
normal  shape ;  when  one  lobe  only  is  involved,  the  gland  be- 
comes unsymmetrical ;  exceptionally  an  adenoma  will  develop 
in  the  isthmus.  As  these  tumours  increase  in  size  the  vesicles 
coalesce,  then  the  septa  gradually  disappear,  and  a  thyroid  cyst 
or  bronchocele  is  formed.  Bronchoceles  sometimes  attain  very 
large  dimensions.  (Fig.  111.)  Their  capsules  are  formed  of 
dense  fibrous  tissue,  which  may  contain  calcareous  plates  ;  in 
some  old  specimens  the  capsules  are  converted  into  calcareous 
shells.  Small  bronchoceles  contain  a  thick  peripheral  stratum 
of  glandular  tissue  ;  their  central  cavities  contain  colloid 
material  or  a  thinner  fluid  of  a  reddish  colour,  due  to  hsemor- 
rhage  ;  not  infrequently  the  fluid  is  largely  charged  with 
cholesterine.  In  very  large  bronchoceles  all  traces  of  gland 
tissue  disappear ;  nothing  remains  but  a  tough,  more  or  less 
calcified  cyst-wall. 

Aug.  Reverdin*  recorded  a  case  in  which  an  old  man  of 
sixty-two  years  had  a  cystic  adenoma  of  the  thyroid  60  cm.  in 
circumference.  On  puncturing  it  a  large  number  of  bodies, 
white  in  colour  and  crenate  like  mulberries,  escaped  with  a 
large  quantity  of  brown  fluid.  Reverdin  stated  that  the 
composition  of  these  bodies  was  like  coagulated  fibrin. 

*  Journal  de  la  Suisse  Momande   1883. 


ADENOMA    AND    CARCINOMA. 


241 


It  is  important  to  bear  in  mind  that  adenomata  of  the  thy- 
roid gland,  large  or  small,  shell  out  quite  easily.  For  example, 
the  exceedingly  large  bronchocele  depicted  in  Fig.  112  was 
successfully  enucleated  by  P.  Bruns.*  The  patient  was  fifty- 
eight  years  old,  and  the  cyst  was  so  large  as  nearly  to  reach 
the  navel.  The  weight  of  the  tumour  produced  lordosis  in  the 
cervical,  and  kyphosis  in  the  thoracic  regions  of  the  spine.  The 
tumour  measured  in  its  horizontal  circumference  61  cm.,  and 


Fig.  111. — Large  unilateral  broncliocele.     {After  Berry.) 

in  a  sagittal  direction  70  cm.  It  was  single-chambered,  and 
the  walls  were  in  parts  calcified.  The  tumour  was  so  heavy 
that  the  woman  was  in  the  habit  of  resting  it  upon  the  table 
when  she  sat  clown. 

Adenomata  and  bronchoceles  occasionally  arise  in  accessory 
thyroids.  Although  it  would  be  approjDriate  to  consider  them 
here,  it  has  been  found  more  convenient  to  discuss  them  in 
relation  with  dermoids  in  chapter  xxxiii. 

Carcinomata. — Cancer  of  the  thyroid  gland  is  an  ex- 
tremely rare  affection  in  England.     In  the  majority  of  cases  it 

*  Bruns,  Beitrage,  bd.  vii.  650. 
Q 


242 


EPITHELIAL    TUMOURS. 


produces  uniform  enlargement  of  the  organ ;  the  gland,  how- 
ever, does  not  attain  large  dimensions.  The  cancerous  portion 
disintegrates,  and  a  cavity  with  shreddy  walls,  containing  dirty 
semi-fluid  material,  is  usually  found  in  one  or  other  of  the  lobes. 
The  walls  of  the  cavity  may  be  calcified.     The  solid  parts  of 


Fig.  112.— Broncliocele  of  unusual  size.    (P.  Bntns.) 

the  cancerous  gland  exhibit  under  the  microscope  alveoli  filled 
with  epithelial  cells.  In  many  of  the  specimens  the  whole  of 
the  normal  tissue  of  the  gland  is  replaced  by  new  growth. 
Cancer  of  the  thyroid  gland  usually  occurs  between  the  ages 
of  forty  and  sixty. 

The  adjacent  lymph  glands  are  early  involved.  Death  fre- 
quently happens  from  early  implication  of  the  inferior  laryngeal 
nerves,  which  leads  to  spasmodic  attacks  of  dyspncea. 

Dissemination  in  the  ordinary  form  of  cancer  of  the  thyroid 


ADENOMA    AND    GAECINOMA. 


243 


gland  is  very  rare,  but  there  is  a  form  of  pulsatile  tumour  of 
bone  associated  with,  if  not  secondary  to,  enlargement  of  this 
gland. 

Several  remarkable  cases  have  been  investigated  clinically 
and  pathologically  in  which  pulsatile  tumours  have  appeared 
in  the  bones  of  the  skull  vault,  at  the  sternal  end  of  the 
clavicle,  in  the  femur,  atlas,  axis,  and  other  vertebrtTe.     These 


/ 


Fig.  113. — Pulsating  tumour  of  tlie  skull,  associated  with  an  enlarged  thyroid.     {From  a 
photograph  in  the  Museum  of  the  Middlesex  Hospital.) 


tumours,  when  examined  histologically,  present  a  structure 
identical  with  that  of  the  thyroid  gland  (Fig.  113);  but  the 
fact  which  invests  them  with  so  much  interest  is  that  they 
have  in  all  instances  been  associated  with  an  obvious  enlarge- 
ment of  this  gland. 

These  tumours  are  excessively  rare,  and  attention  in 
England  was  first  attracted  to  them  by  an  interesting  case 
recorded  by  Mr.  Henry  Morris  in  1880.  The  excellent  account 
of  this  case  is  rendered  more  valuable  by  the  reports  of 
several  distinguished  pathological  histologists  to  whom  portions 


244  EFITHELIAL    TUMOURS. 

of  tlie  growths  were  submitted  for  microscopical  examination. 
(Fig.  114.) 

In  this  case  the  patient,  a  woman  forty-four  years  of  age, 
died  with  a  large  pulsating  tumour  of  the  left  parietal  bone ; 
there  was  also  a  tumour  at  the  sternal  end  of  the  right  clavicle 
and  one  in  the  upper  end  of  each  femur.  She  had,  as  was 
shown  in  her  photograph,  an  enlarged  thyroid  gland.  The 
duration  of  the  case  from  the  time  the  tumour  was  first 
noticed  on  the  skull  until  the  patient  died  was  about  six  years. 

In  the  reports  added  to  the  description  of  this  case  atten- 
tion is  drawn  to  an  example  described  by  Cohnheim,  in  which 
tumours  with  a  structure  similar  to  the  thyroid  gland  were 


S; 

Pig.  114. — Microscopical  appearance  of  tlie  tumour  of  the  skull  iu  preceding  figure. 
{After  H.  Morris.*) 

found  in  the  femur  and  vertebrae.  A  case  is  recorded  by 
Runge  where  tumours  of  the  atlas  and  axis  presented  a 
similar  structure.  In  each  instance  the  thyroid  of  the  patient 
was  enlarged. 

In  1887  Dr.  Coats,-|-  of  Glasgow,  published  a  detailed 
account  of  another  case,  in  which  several  pulsatile  tumours 
appeared  in  the  bones  of  the  skull  vault  which  structurally 
resembled  the  thyroid  gland.  In  this  instance  the  patient,  a 
woman  of  forty-six  years,  had  marked  enlargement  of  the  left 
lobe  of  the  thyroid  gland  ;  this  part  of  the  gland  was  calcified. 
Satisfactory  sections  were  obtained  for  the  microscope,  and  the 
structure  of  the  enlarged  part  of  the  gland  was  found  identical 
with  that  of  the  tumours  on  the  skull. 

*  Trans.  Path.  Soc,  a'oI.  xxsi.  2.59. 

f  Trans.  Path.  Soc,  vol.  xxxviii.   399;  see  also  Haward,  Trans.  Path.  Soc, 
vol.  xxxiii.  291 ;  and  Cohnheim,  Virchow's  "  Archiv,"  bd.  Ixviii.  547. 


ADENOMA    AND    CARCINOMA.  245 

Treatment. — Adenomata  of  the  thyroid  gland  and  broncho- 
celes,  when  of  small  size,  rarely  cause  trouble,  and  an  uni- 
lateral bronchocele  the  size  of  a  closed  fist,  though  it  appears 
unsightly,  is  often  quite  harmless.  Large  bronchoceles  some- 
times cause  pain,  and  when  they  press  upon  the  trachea  give 
rise  to  dyspnoea,  which  will  in  some  cases  become  so  alarming 
as  actually  to  endanger  life.  There  is'  a  very  rare  variety 
known  as  wandering  goitre  on  account  of  its  mobility.  So 
long  as  the  tumour  restricts  its  excursions  to  the  neck  no  harm 
results,  but  occasionally  these  tumours  will  descend  as  low  as 
the  thoracic  inlet.  When  this  happens,  the  bronchocele  be- 
comes squeezed  between  the  manubrium  of  the  sternum  and 
the  trachea.  This  impaction  induces  urgent  symptoms  of 
dyspnoea. 

When,  from  unsightliness  or  other  causes,  it  is  deemed 
necessary  to  interfere  with  an  adenoma  of  the  thyroid  or  a 
bronchocele,  it  is  safe  practice  to  enucleate  them.  The  affected 
lobe  is  exposed  through  a  median  incision,  and  the  thyroid 
tissue  incised  until  the  capsule  of  the  tumour  is  exposed.  By 
means  of  a  raspatory  the  adenoma  can  be  shelled  out  of  its  bed 
quite  easily.  This  method  of  treatment  is  safer  and  quite  as 
efficient  as  thyroidectomy,  and  the  patient  runs  no  risk  of 
hsemorrhage,  tetany,  or  myxoedema. 

The  treatment  of  cancer  of  the  thyroid  gland  by  operation 
is  very  unsatisfactory.  The  procedure  is  one  of  great  difficulty ; 
it  has  a  high  rate  of  mortality,  and  in  cases  that  have 
survived  the  operation  early  recurrence  has  been  the  rule. 

The  Pituitary  Body. — In  its  structure  and  pathological 
tendencies  this  body  resembles  very  closely  the  thyroid  gland. 
It  is  also  liable  to  a  form  of  enlargement  which  is  so  like  a 
parenchymatous  goitre  that  it  might  not  inaptly  be  called  a 
pituitary  goitre. 

As  far  as  I  can  ascertain,  no  one  has  demonstrated  that 
carcinoma  occurs  in  the  pituitary  body.  For  a  summary  of 
our  knowledge  regarding  its  innocent  tumours  the  student 
should  refer  to  page  316. 

THE    PROSTATE. 

After  the  age  of  fifty  years  the  prostate  is  liable  to  become 
greatly   enlarged ;   this   increase   in   size   may  depend   upon 


246 


EPITHELIAL    TUMOUltS. 


aberrant  growth  of  its  muscular  tissue  leading  to  the  formation 
of  myomata,  or  upon  changes  in  the  epithelial  elements 
giving  rise  to  adenoma  or  cancer. 

Adenoma. — It  is  b}^  no  means  rare  for  the  glands  in  the 
prostate  to  enlarge  late  in  life,  so  that  the  organ  becomes  in- 
creased to  twice  or  thrice  its  natural  size  ;  but  there  is  a  varia- 
tion in  the  disposition  oi  the  glandular  elements  of  the 
prostate  that  not  infrequently  renders  the  change  peculiarly 


Vesical  orilice  of  urethra. 


Fig.  115. — Median  prostatic  adenoma,  slvetehed  from  within  the  bladder.      (From  a  man 
sixty  years  of  age.) 

disastrous.  Commonly  the  glands  in  the  prostate  are  arranged 
in  each  lateral  half  of  the  organ  in  such  a  way  that  their  ducts 
open  into  the  urethral  channel  in  the  recess,  or  prostatic  sinus, 
on  each  side  of  the  verumontanum.  In  a  small  proportion  of 
cases  a  collection  of  glands  is  situated  posteriorly  to  the  veru- 
montanum, and  in  such  a  way  as  to  serve  as  an  isthmus 
uniting  the  glands  in  the  lateral  lobes  of  the  prostate.  This 
arrangement  of  glands  has  been  particularly  studied  by  J. 
Griffiths.*  When  a  prostate  in  which  this  third  group  of 
glands  exists  becomes  adenomatous,  the  median  group  also 
enlarges,  and  in  many  cases  projects  into  the  channel  of  the 
urethra,  and  narrows  its  vesical  orifice.  (Fig.  115.)  In  a  typical 
case,  an  adenoma  of  this  kind  consists  of  a  narrow  portion 

*  Journal  of  An  at.  and  Pli>/s.,  vol.  xxiii.,  p.  374. 


ADENOMA    AND    GABGINOMA.  247 

occupying  the  prostatic  urethra,  and  a  prominent  part  pro- 
truding into  the  bladder,  so  that  its  relation  to  the  urethra 
resembles  that  of  a  cork  in  the  neck  of  a  champagne-bottle. 
These  median  prostatic  adenomata  are  covered  by  mucous 
membrane  dotted  with  minute  holes,  which  represent  the  ori- 
fices of  glands  embedded  in  the  tumour.  Small  and  thoroughly 
innocent  in  so  far  as  structure  is  concerned,  this  variety  of 
prostatic  adenoma  often  acts  so  efficiently  as  a  plug  to  the 
urethra  as  to  cause  complete  retention  of  urine,  with  all  its 
evil  consequences. 

Bryant*  has  described  two  cases  in  which,  during  the  per- 
formance of  lateral  lithotomy,  a  median  prostatic  adenoma  was 
accidentally  included  in  the  shanks  of  the  forceps,  in  the  act 
of  grasping  the  stone,  and  torn  off  as  the  instrument  was  with- 
drawn. He  refers  to  a  similar  case  in  Fergusson's  practice. 
Reginald  Harrison  has  also  published  an  instructive  paper  on 
this  subject.f 

Carcinoma. — The  prostate  is  rarely  affected  by  cancer,  and 
this  is  almost  entirely  confined  to  old  men.  As  the  disease 
advances  it  extends  beyond  the  prostate  and  infiltrates  the 
tissues  around  the  base  of  the  bladder.  The  pelvic  lymph 
glands  become  infected,  and  frequently  dissemination  occurs. 

SilcockJ  has  given  a  careful  account  of  a  case  of  prostatic 
cancer  in  Avhich  generalisation  occurred.  The  patient  was 
sixty-one  years  old.  Recklinghausen§  has  published  five 
valuable  cases  of  prostatic  cancer  ;  the  men  were  between 
seventy-two  and  seventy-seven  3^ears  of  age.  It  would  appear 
that  secondary  deposit  in  bone  is  a  very  constant  feature  of 
prostatic  cancer.  This  is  interesting  in  relation  with  the 
peculiar  deposits  in  the  osseous  systena  associated  with  some 
enlarged  thyroid  glands,  as  discussed  in  the  preceding  section. 

Treatment. — With  regard  to  prostatic  adenomata,  the 
difficulty  lies  in  determining  their  existence ;  when  men  over 
fifty-four  years  of  age  suffer  retention  of  urine  from  prostatic 
enlargement  a  pedunculated  adenoma,  as  in  Fig.  115,  may  be 
suspected.     In  some  instances  the  surgeon  has  been  confident 

*  Trans.  Path.  Soc,  vol.  xxix.,  p.  164. 
t  Med.-Chir.  Trans.,  vol.  Ixv.,  p.  39. 
±  Trans.  Path.  Soc,  vol.  xxxv.,  p.  244. 
^Festschrift  to  Virchow,  on  his  71st  hirthday,  1891. 


248  EPITHELIAL    TUMOURS. 

of  his  diagnosis  and  has  removed  it  through  a  suprapubic 
opening  in  the  bladder.*  Radical  treatment  of  prostatic 
cancer  is  beyond  surgical  art. 

THE  PAROTID  GLAND  AND  PANCREAS. 

It  is  so  common  in  clinical  work  to  speak  of  parotid 
tumours,  that  very  few  efforts  have  been  made  to  discriminate 
betAveen  the  various  species  of  tumours  which  arise  in  this 
gland.  In  the  section  of  this  book  devoted  to  sarcomata, 
attention  is  directed  to  the  peculiar  composite  character  of 
parotid  sarcomata  and  their  relative  frequency.  A  careful 
study  of  reported  cases,  as  well  as  observations  I  have  made  on 
patients  under  my  care,  has  served  to  convince  me  that 
adenoma  and  cancer  attack  this  gland. 

Parotid  Adenomata  occur  as  distinctly  encapsuled 
tumours  in  patients  between  fifteen  and  thirty  jenrs  of  age ; 
they  are  painless,  arise  in  any  part  of  the  gland,  and  rarely 
exceed  a  walnut  in  size.  On  section  there  are  usually  cavities, 
hence  such  tumours  are  often  described  as  cysts  of  the  parotid 
gland.  The  walls  of  the  cavities  are  beset  with  wart-like  masses 
which  on  microscopical  examination  exhibit  the  same  struc- 
ture as  the  secreting  tissue  of  the  gland.  In  their  general 
characters  these  tumours  strongly  resemble  the  adenomata  so 
commonly  found  embedded  in  the  thyroid  gland,  and  are 
shelled  out  of  the  parotid  quite  easily. 

Carcinoma  of  the  Parotid. — Little  positive  evidence  is 
forthcoming  in  regard  to  cancer  of  this  gland.  Certain  it 
is  that  those  parotid  tumours  which  appear  in  patients  after 
middle  life,  and,  growing  rapidly,  infiltrate  the  overlying  skin 
and  ulcerate,  conform  to  the  structural  characters  of  cancer.  I 
am  at  the  present  time  unable  to  do  more  than  direct  attention 
to  the  chaotic  condition  of  our  knowledge  regarding  cancer  of 
the  parotid  gland. 

Carcinoma  of  the  Pancreas. — There  is  no  doubt  what- 
ever that  the  pancreas  is  occasionally  the  seat  of  primary 
cancel*.  Judging  from  the  few  examples  of  pancreatic  cancer 
that  have  fallen  into  the  hands  of  competent  pathological 

*  McGill,  Trans.  Clin.  Soc,  vol.  xxi.  p.  52. 


ADENOMA    AND    CARCINOMA.  249 

histologists,  tKe  structure  of  the  tumour  is  a  caricature 
of  tlie  glandular  acini  of  the  pancreas,  although  it  seems  to 
be  the  fashion  to  speak  of  it  as  "  scirrhus  of  the  pancreas." 
Exceptionally  this  cancer  becomes  disseminated.* 

The  chief  interest  of  cancer  of  the  pancreas  lies  in  the  fact 
that  it  is  particularly  liable  to  attack  the  head  of  the  gland 
and  give  rise  to  obstructive  jaundice,  as  it  early  implicates  the 
common  bile  duct. 

An  adenoma  of  the  pancreas  has  yet  to  be  described. 

*  Percy  Kidd,  Trans.    Path.    Soc,    vol.   xxxiv.,    p.    136  ;    Norman.  Moore, 
St.  Earth.  Hosp.  Picp.,  vol.  xvii.,  p.  205. 


>50 


CHAPTER    XXVI. 


ADENOMA    AND    CARCINOMA    OF    THE    LIVER, 
KIDNEY,     OVARY    AND    TESTICLE. 

THE   LIVER. 

The  histological  characters  of  the  liver  render  it  possible  for 
epithelial  tumours,  whether  adenoma  or  carcinoma,  to  imitate 
the  tubular  arrangement  of  the  bile  ducts  or  the  disposition 
of  cells  characteristic  of  a  hepatic  lobule. 

Adenomata. — Fully   developed    adenomata    of    the    liver 
are  encapsuled  tumours  of  a  spherical  shape ;    they  may  be 


0 
Fig.  116. — Adenoma  of  the  liver.     {Aflzr  Paul.-) 
a,  .section  of  blind  duct  filled  witli  green  fluid  ;  b,  liver  celLs  ;  c,  connective  tissue. 

situated  in  any  part  of  the  liver.  Hepatic  adenomata  vary 
greatly  in  size ;  a  solitary  adenoma  may  be  no  larger  than  a 
marble  ;  when  multiple  they  will  be  as  big  as  Tangerine 
oranges.  In  colour  some  are  bright  green,  others  are  dull 
white.  The  peripheral  parts  of  the  tumour  consist  of  solid 
columns  of  cells,  but  on  approaching  the  centre  gradually 
acquire  a  lumen.  These  blind  ducts  are  lined  with  a  single 
layer  of  columnar  epithelium,  and  contain  an  inspissated 
green-coloured  material.  As  the  ducts  make  up  the  bulk  of 
the  tumour  it  is  clear  that  the  olive-s'reen  colour  of  the 
tumour  is  due  to  imprisoned  bile.     In  adenomata  of  this  kind 

*  Trans.  Path.  Soc.  vol.  xxxvi.  238. 


ADENOMA    AND    CARCINOMA.  251 

the  columnar  cells  are  so  striking  that  some  observers  have 
described  these  tumours  as  columnar  epithelial  carcinomata 
of  the  liver.  (Fig.  116.)  In  other  specimens  the  cells,  instead 
of  being  arranged  in  this  tubular  fashion,  are  grouped  around 
a  minute  central  lumen  two  or  more  deep. 

So  far  as  our  knowledge  at  present  extends,  it  would  appear 
that  hepatic  adenomata  as  described  above  are  of  little  clinical 
importance,  and  they  have  been  found  during  the  performance 
of  a  post-mortem  examination  when  the  liver  has  been  sliced 
up  in  the  course  of  the  inspection.  W.  W.  Keen,*  however, 
has  successfully  removed  a  hepatic  adenoma,  measuring 
9  by  6  cm.,  from  a  woman  thirty-one  years  of  age.  The 
circumstance  that  such  tumours  can  be  dealt  with  surgically 
will  lead,  in  all  probability,  to  an  extension  of  knowledge 
concerning  them. 

Carcinomata. — Hepatic  cancer  varies  greatly  in  its  external 
appearance;  sometimes ^  it  assumes  the  form  of  compact 
nodules  of  a  white  colour  projecting  from  the  surface  of  the 
liver  and  visible  on  every  cut  surface,  the  nodules  varying  in 
size  from  a  marble,  or  ripe  cherry,  to  tumours  as  large  as,  and 
even  exceeding  the  fist.  Many  of  the  surface  nodules  present 
a  central  depression  or  umbilicus. 

In  other  cases  the  cancer  assumes  the  form  of  an  irregular 
infiltration  of  soft  growth  of  an  olive-green  colour ;  some  of 
the  tracts  will  assume  a  yellow  colour.  In  all  cases  the  liver 
is  enlarged,  sometimes  to  two  and  even  three  times  its  natural 
size.     The  surface  is  in  most  cases  irregularly  lobulatecl. 

Dissemination  of  the  cancer  is  the  exception ;  secondary 
nodules  have  been  found  in  the  lung,  and  enlarged  lymph 
glands  in  the  portal  fissure ;  in  one  of  the  cases  secondary 
nodules  occurred  in  the  lung,  and  the  mediastinal  lymph  glands 
were  enlarged  and  infiltrated  with  cancer. 

In  point  of  structure  hepatic  cancer  conforms  to  two  types, 
the  tubular  and  the  acinous,  but  the  imitation  in  the  case  of 
cancer  is  not  so  good  as  with  hepatic  adenoma. 

Kindfleisch  in  reference  to  the  tubular  species  of  adenoma 
writes : — "  The  peculiar  intention  which  is  expressed  in  the 
whole  foundation  advances  to  a  delusive  imitation  of  a  tubular 

*  Boston  Med.  and  Surgical  Journal,  April  28,  1892. 


252  EPITHELIAL    TUMOJJIlS. 

R-land."  The  difference  between  the  tiibnlar  adenoma  and  the 
tubular  carcinoma  is  that  the  imitation  is  still  more  delusive, 
and  this  is  equally  true  of  that  which  is  called  the  acinous 
species. 

Clinical  Features. — Hepatic  cancer  occurs  equally  in  men 
and  women,  and  is  most  frequent  between  the  fortieth  and 
sixtieth  years.  An  example  has  been  reported  in  a  boy  of 
fourteen  years. 

Cancer  of  the  liver  leads  to  enlargement  of  this  gland 
and  jaundice,  w^hich  may  be  slight  and  transient  or  of  great 
intensity ;  in  a  few  it  has  only  been  observed  towards  the 
termination  of  life.     Ascites  occurs  in  most  cases. 

Cancer  of  the  Gall  Bladder  is  provisionally  described 
among  the  epitheliomata  (page  215). 

THE    KIDNEY. 

It  is  clear  that  if  the  view  be  correct  that  adenoma  and 
cancer  caricature  the  structure  of  the  glands  in  which  they 
occur,  such  tumours  arising  in  the  kidney  should  be  imita- 
tions of  the  uriniferous  tubules.  As  far  as  my  observations 
have  extended,  the  only  tumour  of  the  kidney  to  which  the 
term  renal  adenoma  is  applicable  is  that  peculiar  condition 
known  as  congenital  cystic  kidney.  It  is  by  no  means  a  rare 
affection.  Nearly  all  the  museums  attached  to  the  London 
hospitals  possess  several  specimens,  and  their  appearance  is  so 
characteristic  that  the  condition  is  not  likely  to  be  over- 
looked. Usually  both  kidneys  are  affected,  but  however  much 
they  may  be  enlarged,  the  natural  shape  is  retained.  The 
kidneys  in  typical  examples  of  this  disease  are  converted  into 
cystic  masses,  so  that  they  exhibit  a  sponge-like  appearance 
on  section.  The  cysts  vary  greatly  in  size ;  some  are  as  small 
as  rape-seed,  others  as  large  as  cherries ;  they  rarely  exceed  these 
dimensions.  Some  of  the  cysts  project  from  the  surface  of 
the  kidney,  but  though  interfering  with  the  smoothness  of  the 
gland,  they  do  not  distort  it.  The  cortical  and  medullary 
portions  of  such  kidneys  are  indistinguishably  blended,  but 
here  and  there  tracts  of  cortical  tissue  may  be  detected  among 
the  cysts.     (Fig.  117.) 

In  the  early  stages  the  cyst-walls  have  a  membrana 
propria,  and  are  lined  with  tesselated  epithelium ;  which  in 


ADENOMA    AND    CABOINOMA. 


25.: 


advanced  specimens  is  clifSciilt  of  detection.  When  tlie 
disease  is  not  far  advanced  the  renal  pelvis  is  easily  recognised, 
but  in  the  later  stages  it  becomes  filled  with  fatty  tissue.  A 
very  striking  feature  in  these  cases  is  the  extreme  narrowness 


Fig.  117. — Congenital  cj-stic  kidney.     (Museum,  Middlesex  Hospital.)     {H.  Morris.) 


of  the  ureter,  and  yet  in  all  the  cases  that  have  come  under 
my  observation  it  has  been  pervious  throughout.  The  vessels 
supplying  such  kidneys  are  always  small. 

.The  kidneys  when  congenitally  cystic  sometimes  attain  an 
enormous  size — so  large  indeed  that  they^  seriously  impede 
labour,  and  often  necessitate  destruction  of  the  fcetus  in  order 
to  enable  delivery  to  be  effected :  in  a  large  proportion  of 
cases  in  which  the  foetus  comes  away  without  difficulty  it  is 


254 


EPJTJIEL  TA  L    TUMO  URS. 


still-born  and  often  nialfornicd ;  such  conditions  as  anence- 
plialia,  club-foot,  and  spina  bifida  are  often  found  associated 
with  congenital  cystic  disease  of  the  kidneys.  Minor  degrees 
of  the  affection  are  not  incompatible  with  life,  and  several 
instances  are  known  in  which  such  kidneys  have  been  found 
in  adult  individuals. 

Virchow  seems  to  have  been  one  of  the  first  to  study  this 


Fig.  US.— Congenital  cystic  kidney  ;  early  stage.     {Shattook.) 

condition  particularly,  and  he  regarded  the  cysts  as  dilatations 
of  the  uriniferous  tubules  in  consequence  of  the  absence  of  a 
renal  pelvis.  This  explanation  is  not  good,  for  as  has  already 
been  mentioned,  the  pelvis  may  be  demonstrated  in  early 
specimens.  (Fig.  118.)  I  have  dissected  twenty  examples 
without  succeeding  in  finding  any  evidence  of  obstruction  in 
the  urinary  tract.  The  only  example  which  gives  the  least 
colour  to  the  suggestion  that  these  cysts  are  due  to  hindrance 
to  the  escape  of  urine  is  one  described  by  Shattock,*  in  which 

*  Trans.  Path.  Soc,  vol.  xxxix.  185. 


ADEN02IA    AND    CARCINOMA. 


255 


an  embiyo  of  tlie  fourth  month  with  an  imperforate  urethra, 
had  an  enormously  distended  bladder  and  congenitally  cystic 
kidneys,  but  the  ureters  were  not  dilated. 

It  is  pointed  out  in  chapter  xlii.  that  in  the  foetus, 
obstruction  to  the  flow  of  urine  leads  to  hydronephrotic 
changes  similar  to  those  which  occur  in  the  adult. '"^Care- 
fid   consideration   of  the  evidence  shows  that   the  cysts,  in 


Fig.  119.— Adenoma  of  the  kidney.     (IV.  EdmuRils.) 

congenital  cystic  disease  of  the  kidney,  are  not  the  result  of 
obstruction. 

Shattock*  has  advanced  the  opinion  based  on  careful 
histological  researches  that  in  these  kidneys  we  have  to  deal 
with  a  combination  of  mesonephros  (Wolffian  body)  with  the 
metanephros  (true  kidney),  and  the  cysts  may  be  regarded 


''  Trans.  Path.  Soc,  vo].  xxxvii.  287. 


256  EPITHELIAL    TUMOURS. 

as  arising  in  remnants  (or  rests)  of  the  inesonephros  embedded 
in  the  true  kidney.  My  own  inquiries  lead  me  to  regard  this 
view  as  probable  ;  it  is  certainly  more  satisfactory  than  the 
retention  view  advanced  by  Virchow.* 

Dr.  W.  Edmundsf  has  described  a  specimen  which  is 
interesting  in  relation  to  the  opinion  that  the  phrase  "  con- 
genital cystic  kidney "  might  with  great  convenience  be 
replaced  by  the  term  "  renal  adenoma."  In  a  kidney  removed 
from  a  girl  eighteen  years  old,  an  encapsuled  tumour  was 
found  projecting  into  one  of  the  calyces  (Fig.  119).  It  had  a 
diameter  of  6  cm.  and  consisted  of  a  congeries  of  cysts  lined 
with  cubical  epithelium,  and  in  every  way  comparable  to 
those  represented  in  Fig.  117. 

Carcinoma. — In  considering  renal  cancer  we  are  involved 
in  as  much  difficulty  as  with  renal  adenoma.  It  has  been  so 
much  the  fashion  with  surgeons  to  describe  malignant  tumours 
of  the  kidney  under  the  meaningless  title  of"  encephaloicl "  that 
we  have  no  histological  data  to  guide  us  in  determining  the 
nature  of  such  tumours.  However,  I  am  convinced,  from  my 
own  investigations,  that  a  large  proportion  of  such  tumours 
are  in  reality  sarcomata,  but  I  am  equally  certain  that  in  a 
few  "  encephaloid  "  tumours  of  the  kidney,  abnormal  develop- 
ment of  epithelium  is  a  distinguishing  feature. 

A  good  example  of  a  renal  epithelial  tumour  has  been 
described  by  Sharkey.  J  The  description  is  accompanied  by  a 
careful  drawing  of  the  microscopical  features  of  the  tumour ; 
in  some  parts  of  it  there  were  alveoli  lined  with  regularly 
arranged  columnar  epithelium.  "  In  such  parts  the  tumour 
presented  a  rough  but  striking  resemblance  to  the  tubular 
structure  of  the  kidney." 

Judging  from  some  specimens  I  have  examined  there  can 
be  little  doubt  that  malignant  tumours  are  occasionally  met 
with  in  the  kidney  which  are  essentially  epithelial  in  origin. 
It  is,  however,  impossible  to  write  an  account  of  carcinoma  of 
the  kidney  until  surgeons  are  more  alive  to  the  interest  of  the' 
question  and  take  steps  to  place  malignant  tumours  of  the 

*  Ueber  Congenitale  Nierenwassersucht,  Gesammelte  Abhandlungen,  p.  839. 
{See  also  Pye-Smitli,  Trans.  Path.  Soc,  vol.  xxxii.  112.) 
f  Trans.  Path.  Soc.  vol.  xliii.  89. 
:|;  Trans.  Path.  Soc,  vol.  xxxv.  235. 


ADENOMA  AND   CARCINOMA.  257 

kidney,    whilst    still    fresli,    in    the    hands    of    experienced 
pathological  histologists. 

THE    OVARY. 

There  is  no  glandular  organ  of  the  body  which  is  liable  to 
such  an  extraordinary  variety  of  tumours  as  the  ovary.  The 
chief  features  of  the  innocent  epithelial  ovarian  tumours  are 
epitomised  in  the  section  devoted  to  dermoids.  (Chapter 
xxxvii.)  Of  these,  there  is  one  variety  especially  described  as 
ovarian  adenoma,  so  that  it  will  be  unnecessary  to  devote 
space  to  it  here  except  to  remark  that  it  is,  in  point  of 
structure,  in  no  sense  an  imitation  of  the  true  tissue  of 
the  ovary. 

In  regard  to  primary  cancer  of  the  ovary  very  little  reliable 
evidence  is  forthcoming.  Many  cases  have  been  described  in 
which  the  ovary  has  become  transformed  into  a  large  tumour 
which,  under  the  microscope,  presented  an  alveolar  disposition 
of  cells ;  but  such  specimens  have  for  the  most  part  occurred 
in  children,  whereas  cancer  in  every  other  gland  is  a  disease  of 
adult  life.  This  fact  alone  should  make  us  pause  before  de- 
ciding simply  on  the  alveolar  constitution  of  a  tumour  that  it 
is  cancer.  Nevertheless,  malignant  tumours  are  occasionally 
seen  in  the  ovaries  of  individuals  past  middle  life,  in  which 
epithelium  plays  a  very  characteristic  part.  Such  tumours 
also  exhibit  the  clinical  features  of  cancer,  in  that  they  infect 
the  peritoneum  and  very  rapidly  destroy  life. 

It  is  quite  possible  that  the  rarity  of  such  tumours  in 
part  explains  the  absence  of  accurate  knowledge  concerning 
them.     It  is  a  subject  needing  very  careful  investigation. 

THE   TESTICLE. 

The  infrequency  of  tumours  of  the  testicle  stands  in 
striking  contrast  to  the  frequency  with  which  they  occur  in 
the  ovary.  Formerly  it  was  the  fashion  to  describe  all 
malignant  tumours  of  the  testicle  as  cancer;  of  late  years 
it  has  been  ascertained  that  by  far  the  greater  number  are 
sarcomata. 

As  to  whether  adenomata  and  cancers  that  caricature  the 
secreting  structure  occur  in  the  testicle,  nothing  definite  is 
known.  So  far  I  have  been  unable  to  recognise  such  a  speci- 
men.    There  is  a  variety  of  adenoma  that  originates  in  the 

R 


258  EPITHELIAL   TUMOUIiS. 

paradidymis  ;  it  is  very  similar  in  structure  to  a  renal  adenoma, 
but  it  is  in  no  way  connected  with  the  secreting  tissue  of 
the  testicle.     {See  chapter  xliv.). 

Malignant  tumours  of  the  testis  require  careful  investiga- 
tion, conducted  on  a  full  supply  of  material,  accompanied  by 
complete  clinical  histories. 


259 


CHAPTER    XXVII. 

ADENOMA   AND   CARCINOMA   OF   THE   STOMACH, 
INTESTINES,  AND  RECTUM. 

THE    STOMACH. 

Adenoma. — Yery  little  attention  has  been  devoted  to  tlie 
study  of  adenoma  of  tlie  stomacli ;  this  is  due  to  the  fact  that 
it  occurs  in  the  immediate  vicinity  of  the  pylorus,  and  like 
carcinoma  in  this  situation,  blockades  the  strait  by  which  the 
stomach  and  duodenum  are  connected,  and  leads  to  starvation. 
Hence  as  the  clinical  effects  are  practically  identical  with 
those  induced  by  cancer  of  the  pylorus,  few  efforts  have  been 
made  to  differentiate  the  varieties  of  pyloric  tumours. 

A  gastric  adenoma  is  usually  ovoid  when  it  involves  the 
pylorus,  and  sometimes  forms  a  tumour  as  large  as  a  fowl'- 
egg.  When  it  attains  such  a  size  as  to  drag  upon  the  attach 
ment  of  the  pyloric  end  of  the  stomach  it  may  come  to 
occupy  a  position  on  a  level  with,  or  even  below,  the  umbilicus, 
and  is  sometimes  so  mobile  that  it  may  be  shifted  into  ah  the 
regions  of  the  abdomen.  The  structure  of  an  adenoma  in  the 
neighbourhood  of  the  pylorus  is  a  repetition  of  the  pyloric 
glands. 

Carcinoma. — This  disease  is  by  no  means  rare  in  the 
stomach.  The  records  of  most  general  hospitals  in  London, 
capable  of  accommodating  one  hundred  medical  patients,  show 
a  yearly  average  of  six  cases. 

In  structure,  srastric  cancer  mimics  the  tubular  sflands 
which  are  so  numerous  in  the  mucous  membrane  of  the 
stomach. 

Concerning  the  mode  in  which  the  affection  begins,  no  pre- 
cise information  is  forthcoming  ;  it  is  commonly  situated  at,  or 
in,  the  immediate  neighbourhood  of  the  pylorus.  "  If  a  line  be 
drawn  from  one  inch  (2-5  cm.)  to  the  left  of  the  oesophagus,  to 
a  point  on  the  lower  border  of  the  stomach  four  inches  (10  cm.) 
from  the  pylorus,  the  part  to  the  left  of  this  line  will  be  found 
to  suffer  very  rarely  from  cancer.  The  rest  of  the  surface,  the 
right  and  upper  part,  is  the  peculiar  seat  of  cancer  "  (Wilks 
and  Moxon). 


260  EPITHELIAL   TUMOUBS. 

In  the  early  stages  the  disease  is  limited  to  the  inucoiis 
membrane  ;  it  then  invades  the  muscular  and,  in  a  fair  propor- 
tion of  cases,  the  serous  coats.  The  infiltration  of  the  tissues 
about  the  pylorus  leads  to  its  obstruction,  which  is  often  so 
extreme  that  an  ordinary  probe  can  scarcely  traverse  it.  The 
mucous  surface  of  the  tumour  ulcerates,  sloughs,  and  bleeds. 
Occasionally  the  pyloric  branch  of  the  hepatic  artery  is  eroded, 
and  the  bleeding  may  be  so  profuse  as  to  terminate  life  in 
patients  whose  strength  has  been  reduced  by  small  hsemor- 
rhages,  frequently  repeated,  from  the  ulcerating  surface  of  the 
cancer.  Whilst  these  changes  are  in  progress  on  the  mucous 
aspect  of  the  tumour  the  subserous  tissues  become  infiltrated, 
the  overlying  peritoneum  is  involved,  and  adhesions  form 
between  it  and  the  omentum,  the  parietal  peritoneum,  liver, 
and  occasionally  the  transverse  colon. 

The  extent  to  which  the  disease  infiltrates  the  surrounding- 
parts  varies  greatly.  In  a  large  number  of  cases  it  remains 
restricted  to  a  zone  extending  3  cm.  on  each  side  of  the 
pylorus ;  exceptionally  it  will  implicate  the  duodenum  as 
low  as  the  orifice  of  the  common  bile  duct.  More  often  the 
disease  creeps  along  the  lesser  curvature  of  the  stomach. 
When  the  cardiac  orifice  is  attacked,  the  cancer  will  extend 
into  the  oesophagus  and  downwards  along  the  lesser  curvature. 

For  a  time  the  disease  remains  restricted  to  the  walls  of 
the  stomach,  but  later  it  spreads  along  the  adhesions  to  such 
structures  as  the  liver,  pancreas,  gall  bladder,  duodenum,  colon, 
spleen,  and  diaphragm  ;  then,  as  ulceration  follows,  it  happens 
that  the  floor  of  the  ulcer  will  be  formed  by  the  liver,  the 
pancreas,  or  the  spleen.  When  such  parts  as  the  colon  or 
duodenum  form  the  base  of  the  ulcer,  perforation  occurs, 
and  a  gastro-colic  or  gastro-duodenal  fistula  is  formed.  It 
is  a  singular  fact  that  these  fistulas  are  more  common  with 
cancerous  than  with  the  simple  forms  of  gastric  ulcers. 

The  lymph-glands  in  the  gastro-hepatic  omentum  are 
infected  in  more  than  half  the  cases  ;  extensive  enlargement 
of  the  lumbar  glands  sometimes  happens,  and  those  lying  in 
the  posterior  mediastinum  maybe  infected;  the  mfection,  in  ex- 
ceptional cases,  may  extend  to  the  glands  at  the  root  of  the  neck. 

Dissemination  is  the  rule  with  cancer  of  the  stomach.  The 
secondary  nodules  usually  make  their  appearance  in  the  liver 


ADENOMA  AND   CARCINOMA. 


261 


and  the  lungs.    Secondary  nodules  are  frequently  found  in  one 
or  both  ovaries. 

Finlay*  has  recorded  a  case  in  which  a  cancer  originating 
at  the  cardiac  orifice  of  the  stomach  became  widely  dis- 
seminated,  and  the  skin  of  the  trunk  was  thickly   studded 


Fig.  120. — So-called  colloid  of  the  oirientum. 

with  hard  subcutaneous  nodules  varying  in  size  from  a  pea  to 
a  walnut.  There  were  a  few  nodules  on  the  arms  and  legs.  The 
lymph  glands  in  the  groins  and  axillge  were  enlarged.  During 
life  two  nodules  were  excised,  and  when  examined  micro- 
scopically were  found  to  consist  of  alveoli  lined  with  columnar 
epithelium.  This  circumstance  indicated  that  the  primary 
growth  was  in  the  alimentary  canal,  although  during  life  its 
precise  locality  could  not  be  fixed. 

There  is  a  curious  and  somewhat  rare  condition   of  the 

■'  Trans.  Path.  Soc,  vol.  xxxiv.  102. 


•262  EPITHELIAL   TUMOURS. 

omentum  associated  with  cancer  of  tlie  stomach.  That  it  is 
httle  understood  may  be  inferred  from  the  variety  of  names 
apphed  to  it : — colloid  or  hydatid  tumour ;  colloid  cancer ; 
myxo-sarcoma  of  the  omentum.  There  can  be  little  doubt 
that  the  uncertainty  of  knowledge  concerning  it  is  very 
largely  due  to  its  rarity.     (Fig.  120.) 

In  typical  cases  the  omentum  is  greatly  thickened  (5  to 
10  cm.),  and  it  may  weigh  upwards  of  ten  pounds.  The 
surface  is  fiocculent,  and  on  close  inspection  small  rounded 
collections  of  gelatinous  material  may  be  seen  in  the  midst  of 
the  villous  processes ;  some  of  them  are  stalked  and  look  like 
white  currants.  On  microscopical  examination  the  bulk  of 
the  omentum  is  made  up  of  myxomatous  tissue,  but  here  and 
there  collections  of  epithelial  cells  are  found  surrounded  by 
incomplete  capsules  of  fibrous  tissue.  The  general  impression 
I  have  formed  from  an  examination  of  the  only  specimen 
that  has  come  under  my  observation  is,  that  the  condition  is 
due  to  infiltration  of  the  great  omentum  from  a  cancerous 
stomach,  and  the  cancerous  material  with  the  proper  omental 
tissue  undergoes  colloid  or  myxomatous  degeneration.  The 
subject  requires  the  close  investigation  of  perfectly  fresh 
material  for  its  proper  elucidation. 

Clinical  Features. — Cancer  of  the  stomach  is  rare  before 
the  thirtieth  year ;  it  is  most  common  between  the  fortieth 
and  sixtieth  years ;  it  has  been  demonstrated  as  early  as 
thirteen ;  it  occurred  near  the  cardiac  end  of  the  viscus,  and 
the  patient  was  a  girl.* 

Gastric  carcinoma  runs  a  very  rapid  course,  life  being 
rarely  prolonged  beyond  twelve  months  from  the  time  the 
disease  is  first  recognised.  Its  rapidly  fatal  course,  especially 
when  the  pylorus  is  implicated,  is  largely  due  to  the  obstruc- 
tion offered  to  the  escape  of  food  into  the  duodenum ;  hence 
it  is  retained  in  the  stomach,  which  often  becomes  dilated 
into  a  huge  sac,  sometimes  reaching  as  low  as  the  pubes. 
Fermentation  of  the  retained  and  partially  digested  food 
occurs,  and  the  contents  of  the  stomach  are  vomited  at  irregular 
intervals,  mixed  with  altered  blood  which  escapes  from  the 
ulcerated  surface  of  the  tumour. 

*  Norman  Moore,  Trans.  Path.  Soc,  vol.  xxxvi.  195. 


ADENOMA  AND   CARCINOMA.  263 

When  cancer  involves  the  cardiac  oritice,  the  stomach 
is  usually  contracted.  Cancer  of  the  stomach  causes  death 
in  various  ways.  Of  these  the  chief  are  : — exhaustion  due  to 
starvation  and  frequent  heemorrhage ;  perforation  into  the 
general  peritoneal  cavity  and  fatal  peritonitis.  In  exceptional 
instances  the  diaphragm  is  perforated  and  fatal  pleurisy 
ensues. 

THE    INTESTINES   AND    RECTUM. 

Adenoma  and  carcinoma  occur  in  all  parts  of  the  intestine, 
from  the  duodenum  to  the  anus,  but  they  occur  most 
frequently  in  the  rectum.  This  fact,  and  the  circumstance 
that  the  rectum  is  accessible  to  clinical  examination  have 
led  surgeons  to  study  rectal  tumours  with  much  care.  It  is 
useful  to  illustrate  the  general  features  of  adenoma  and 
cancer  of  the  intestine  from  the  facts  obtained  by  a  study  ol 
these  tumours  as  they  occur  in  the  rectum,  for  they  all  conform 
to  the  same  histological  type. 

The  prevailing  type  of  gland  in  the  intestine  is  the  Lieber- 
klihnian  follicle.  Enough  evidence  has  been  adduced  in  the 
preceding  sections  to  prepare  us  for  the  fact  that  intestinal 
adenomata  would  be  reproductions  of  these  glands,  and  that 
the  carcinomata  would  caricature  them.  If  to  these  glands 
we  add  occasional  clusters  of  adenoid  follicles  in  the  cancers, 
then  the  mimicry  will  be  complete. 

Adenomata  of  the  Rectum. — These  tumours  occur  in  the 
form  of  polypoid  outgrowths  of  the  mucous  membrane, 
especially  in  young  children.  In  some  cases  they  are  no 
larger  than  peas;  in  others  rectal  polypi  may  be  as  big  as 
walnuts.  When  large  an  adenoma  is,  as  a  rule,  solitary; 
when  multiple  they  are  generally  small.  It  is  rare  for  them 
to  be  present  in  great  number.  The  large  solitary  adenoma 
is  attached  to  the  mucous  membrane  by  a  fairly  thick  stalk ; 
in  life  the  tumour  and  its  pedicle  has  the  same  deep  red 
colour  as  the  inner  wall  of  the  gut,  and  is  generally  closely 
pitted  with  minute  dots ;  these  are  the  orifices  of  the  mucous 
glands. 

On  section  the  greater  part  of  the  adenoma  will  be  found 
to, consist  of  vascular  connective  tissue  ;  over  this  is  spread  a 
layer  of  mucous  membrane  beset   with  large   follicles   lined 


264 


EPITHELIAL   TUMOURS. 


with  a  single  layer  of  tall  columnar  epithelium.     The  follicles 
are,  as  a  rule,  filled  with  thick  mucus.     (Fig.  106). 

An  adenoma  occasions  local  trouble  only;  when  attached 
within  6  or  8  cm.  of  the  anus — and  this  is  the  usual 
situation  in  which  to  find  it  —  the  pedicle  gradually 
elongates  until  it  is  long  enough  to  allow  the  adenoma  to  be 
carried  beyond  the  sphincter  during  defsecation ;  it  is  then 


Fig.  121. — Cancer  of  the  sigmoid  flexure  of  the  colon. 

liable  to  be  caught  and  strangulated.  This  is  sometimes 
curative,  for  the  tumour,  or  "  polypus  "  as  it  is  usually  called, 
sloughs. 

Carcinoma  of  the  Rectum. — In  its  early  stages — that  is, 
when  it  becomes  clinically  recognisable — cancer  of  the  rectum 
projects  from  the  mucous  membrane  as  a  hard  tuberous  mass ; 
the  surface  of  the  tumour,  irritated  by  the  passage  of  faeces, 
ulcerates  and  forms  a  foul,  crater-like  ulcer.  The  cancer  tends 
to  spread  at  its  jjeriphery  and  extend  round  the  bowel;  at 
length  it  projects  as  a  thick  circular  diaphragm,  and  so 
narrows  the  gut  that  the  passage  becomes  contracted  until 
no  wider  than  a  crow-quill.     (Fig.  121.)     In  some  specimens 


ADENOMA  AND   GABCINOMA. 


265 


the  lumen  'of  the  bowel  is  not  so  much  narrowed  by  the 
exuberance  of  the  growth  as  by  the  contraction  it  exercises 
upon  the  intestinal  wall.  Sometimes  the  tumour  will  have  a 
diameter  of  2  cm.  and  less,  j^et  its  power  of  contraction  is  so 
great  that  jt  completely  obstructs  the  bowel.  This  variet}^  is 
more  frequent  in  the  colon  than  in  the  rectum.  (Fig.  122.) 
In  some  cases  the  disease,  instead  of  forming  a  localised 


Fig.  122. — Cancer  of  colon  (constricting  variety). 

tuber,  tends  from  the  first  to  infiltrate  the  muscular  as  well  as 
the  submucous  tissues,  and  even  extends  beyond  the  confines 
of  the  gut  to  adjacent  parts  such  as  the  peritoneum,  pelvic 
connective  tissue,  prostate,  or  vagina.  Ulceration  occurs  early 
in  this  variety.  Whilst  in  one  case  the  cancer  tends  to  pene- 
trate the  wall  of  the  rectum,  in  another  it  will  form  larsre  and 
exuberant  masses,  blocking  up  the  gut  and  even  protruding 


266  EPITHELIAL   TUMOURS. 

beyond  the  anus.  It  may  in  a  third  case  be  restricted  to  a 
narrow  area  of  the  bowel,  and  remain  apparently  indolent  for 
a  long  period. 

Rectal  carcinoma  consists  of  glandular  recesses,  lined  with 
tall  columnar  cells,  embedded  in  a  stroma  of  dense  connective 
tissue.  In  order  to  make  out  the  nature  of  the  growth,  sec- 
tions should  be  taken  from  the  margins  of  the  tumour,  because 
the  deeper  parts  are  much  altered  by  ulcerative  and  necrotic 
changes.  As  a  matter  of  fact,  in  many  cases  of  rectal  cancer, 
judging  merely  from  the  appearances  under  the  microscope,  it 
would  be  diflficult  to  determine  whether  the  section  was  pre- 
pared from  an  adenoma  or  a  carcinoma ;  but  it  must  be  borne 
in  mind  that  the  adenoma  remains  restricted  to  the  mucous 
membrane,  whereas  in  cancer  we  find  the  glands  with  their 
characteristic  columnar  cells  interspersed  among  the  muscular 
fasciculi  of  the  gut-wall.  The  proportion  of  connective  tissue 
varies  greatly.  In  some  cancers  the  glands  are  closely  set;  in 
others  they  are  ill-formed,  arranged  irregularly,  and  embedded 
in  an  abundance  of  connective  tissue.  Occasionally  collections 
of  lymphoid  tissue  are  observed.  Harrison  Cripps  states  that 
when  a  rectal  cancer  invades  the  anus,  the  part  of  the  tumour 
which   involves   the  anus  loses  its  glandular  character  and 

o 

assumes  the  form  of  a  squamous-celled  epithelioma.  For 
beautiful  illustrations  of  the  histology  of  rectal  cancer  the 
student  should  consult  Cripps's  papers.*  Rectal  cancer  is  very 
rare  before  the  age  of  twenty ;  it  is  commonly  met  with 
between  the  thirtieth  and  fifty-fifth  years. 

The  pelvic  and  lumbar  lymph  glands  are  first  involved, 
then  those  glands  lying  in  the  course  of  the  external  iliac 
artery.  Should  the  skin  of  the  anus  become  infiltrated,  then 
the  inguinal  lymph  glands  may  be  infected.  The  liver  is  the 
eat  of  secondary  deposits  in  a  large  proportion  of  cases  of 
rectal  cancer.  Occasionally  widespread  dissemination  occurs, 
and  nodules  are  formed  not  only  in  the  liver,  but  in  the  lungs, 
kidneys,  and  bones.  Few  things  are  more  surprising  than  on 
examining  a  cancer  nodule  from  the  liver,  or  from  a  long  bone 
like  the  humerus,  to  find  Lieberktihn's  glands,  with  their  tall 
columnar  epithelium. 

When  rectal  cancer  invades  the  peritoneum,  this  serous 

*  Trans.  Path.  Soc,  vols,  xxxii.  87,  and  xxxiii.  IGo. 


ADENOMA  AND  CARCINOMA.  267 

membrane  will  sometimes  become  dotted  over  with  minute 
elevations  like  sago  grains. 

Carcinoma  of  the  Intestine. — Cancer  of  tlie  small  and  large 
intestine  is  of  the  same  structure,  and  has  the  same  relation  to 
the  gut  as  that  which  occurs  in  the  rectum.  The  liability  of 
the  various  sections  of  the  intestine  to  cancer  varies  greatly. 
In  the  duodenum,  jejunum,  and  ileum  this  disease  is  very 
rare ;  it  has  on  a  few  occasions  been  observed  at  the  ileo-caecal 
valve,  and  is  not  unknown  at  the  orifice  of  the  common  bile 
duct.  In  the  large  bowel,  excluding  the  rectum,  cancer  is  fairly 
frequent,  and  exhibits  a  curious  tendency  to  occur  at  the  sig- 
moid, splenic,  and  hepatic  flexures.  The  relative  frequency  with 
which  the  various  parts  of  the  intestine,  from  the  beginning 
of  the  duodenum  to  the  anus,  are  attacked  by  cancer  may  be 
represented  in  the  following  way  : — 

Of  every  one  hundred  cases,  seventy-five  occur  in  the 
rectum ;  of  the  remainder,  twenty-three  would  be  localised  in 
the  large  bowel  and  two  in  the  small  intestine,  including  the 
ileocsecal  valve,  and  would  probably  be  distributed  in  the 
following  manner  : — 


Small  intestine  and  ileo-csecal  valve 

Caecum 

Hepatic  flexure  of  colon 

Splenic  flexure  of  colon 

Sigmoid  flexure 

Intermediate  sesinents  of  colon 


2 
2 
3 

4 
10 

4 

25 


Of  the  intermediate  segments  of  the  colon  the  transverse 
is,  perhaps,  the  most  frequent  situation  for  cancer.  A  search 
through  the  home  literature  indicates  that  very  few  records  of 
cancer  of  the  ileo-ceecal  valve  exist.* 

Concerning  the  mode  in  which  cancer  of  the  small  intes- 
tine, csecum,  and  colon  begins  nothing  is  known.  The  symp- 
toms to  which  it  gives  rise  are  those  of  intestinal  obstruction, 
and  is,  in  most  cases,  a  matter  of  conjecture,  mainly  based  upon 
the  age  of  the  patient  and  the  gradual  manner  in  which  the 
signs  develop,  when  the  surgeon  arrives  at   the  conclusion 

*  Hawkins,  Trans.  Path.  Soc,  vol.  xlii.,  p.  132. 


268  EPITHELIAL   TUMOURS. 

that  the  trouble  is  due  to  cancer  in  some  part  of  the  large  in- 
testine. As  far  as  I  am  aware,  the  diagnosis  of  primary  cancer 
of  the  small  intestine  has  not  been  made,  for  when  seated  in 
the  small  gut  below  the  duodenum,  cancer  usually  gives  rise  to 
signs  of  acute  obstruction.  From  this  it  follows  that  our 
knowledge  of  intestinal  cancer  is  based  upon  a  study  of  the 
disease  in  its  advanced  stage.  One  of  its  most  characteristic 
features  is  the  way  it  travels  round  the  gut  and  forms  a  zone 
of  hard  material  projecting  into  its  lumen,  and  then,  as  it  con- 
tracts, the  diseased  parts,  as  seen  from  the  outside,  look  as  if 
the  intestine  had  been  girt  with  a  tight  ligature.  In  the  later 
stages  the  lumen  of  the  gut  becomes  so  straitened  that  nothing 
but  a  narrow,  tortuous  channel  traverses  the  cancerous  mass, 
and  this  alloAvs  the  liquid  faeces  retained  in  the  dilated  segment 
of  the  gut  on  the  proximal  side  of  the  tumour,  gradually  to 
trickle  through,  and  at  times  even  this  limited  channel  of 
escape  becomes  closed.  Occasionally,  after  many  days  of  com- 
plete obstruction,  a  portion  of  the  cancer  sloughs,  and  the 
obstruction  is  temporarily  relieved.  The  enormous  quantity 
of  faeces  that  escapes  on  such  occasions  is  almost  beyond 
belief. 

A  large  proportion  of  patients  with  intestinal  cancer 
succumb  from  the  effects  of  obstruction;  in  others  death  is 
brought  about  by  other  means.  For  example,  the  retention  of 
the  contents  of  the  bowel  leads  to  dilatation  of  the  gut  above 
the  stricture ;  this  may  induce  ulceration  and  gangrene,  which 
terminates  in  perforation.  In  this  event  the  effect  depends  on 
the  part  of  the  gut  perforated.  Should  the  opening  aUow 
faecal  matter  to  escape  into  the  peritoneal  cavity,  peritonitis  is 
the  consequence,  and  as  a  rule,  kills  the  patient  in  a  few  hours. 
In  the  case  of  the  caecum,  the  ascendiDg  or  descending  colon, 
the  extravasation  may  take  place  behind  the  peritoneum  and 
give  rise  to  a  faecal  abscess.  Such  abscesses  in  connection 
with  the  right  colon  will  point  in  the  neighbourhood  of 
Poupart's  ligament  (usually  above,  but  sometimes  below  this 
band),  or  at  the  crest  of  the  ileum.  I  have  known  pus  from  an 
abscess  of  this  kind  in  connection  with  the  descending  colon, 
travel  between  the  muscular  planes  of  the  belly-wall  as  far 
as  the  linea  semilunaris,  and  the  intestinal  gas  caused  the 
whole  of  the  left  half  of  the  belly- wall  to  be  emphysematous. 


ADENOMA  AND   CARCINOMA.  269 

In  chronic  intestinal  obstrnction  clue  to  cancer  of  the 
descending  colon,  the  Cfecnm  becomes  gTeatly  distended 
with  fluid  feces;  this  leads  to  ulceration  of  its  wall,  which 
occasionally  perforates  and  sets  up  rapidly  fatal  peritonitis. 

It  occasionally  happens  that  a  distended  coil  of  bowel 
immediately  above  a  cancerous  stricture  will  adhere  to  an 
adjacent  piece  of  healthy  intestine,  which  will  be  infiltrated  by 
the  cancer :  sloughing  follows,  and  a  fistula  forms  between  the 
implicated  coils.  Such  an  event  rarely  improves  the  patient's 
condition,  as  the  communication  almost  always  takes  place 
with  a  piece  of  intestine  on  the  proximal  side  of  the  stricture. 
It  has  happened  to  me  on  three  occasions  to  meet  with  cancer 
in  the  loop  of  a  U-shaped  colon.  The  convexity  of  the  loop 
had  in  two  instances  come  in  contact  with,  and  perforated 
into  the  bladder.  Uterine  cancer  sometimes  perforates  into 
the  peritoneal  cavity  and  implicates  the  colon ;  hence  care 
is  necessary  in  discriminating  between  a  cancerous  colon 
adherent  to  the  uterus,  and  a  cancerous  uterus  implicating 
the  colon.  Cancer  of  the  sigmoid  flexure  is,  in  a  large  pro- 
portion of  cases,  localised  in  that  portion  of  the  flexure  in 
relation  with  the  brim  of  the  true  pelvis,  and  it  is  a  curious 
fact  that  in  such  cases  the  left  ovary  is  often  adherent  to,  and 
occasionally  forms  the  base  of  a  cancerous  ulcer  in  this  part 
of  the  colon. 

Briefly  summarised,  the  modes  of  death  in  cancer  of  the 
intestines  are  : — Intestinal  obstruction,  intussusception,  per- 
foration into  the  peritoneal  cavity,  and  suppurative  nephritis 
when  the  disease  is  in  the  rectum  and  involves  the  ureters. 

Treatment. — The  ideal  treatment  of  cancer  of  the  ali- 
mentary canal  from  the  pylorus  downwards  is  excision  of  the 
tumour.  In  the  case  of  the  rectum  this  mode  of  treatment 
has  been  practised  very  extensively  and  with  a  gratifying- 
measure  of  success. 

In  the  higher  region  of  the  intestine — such,  for  instance, 
as  the  colon  and  the  pylorus — it  is  not  only  necessary  to 
resect  the  whole  circumference  of  the  gut,  but  to  adopt 
measures  to  unite  the  cut  ends  of  the  intestine  or  stomach,  as 
the  case  may  be,  in  such  a  way  as  to  insure  the  continuity  of 
the  lumen  of  the  canal,  and  this  union  must  be  so  perfect 
that    no    bowel    contents    or    secretions    can   leak    into    the 


270  EPITHELIAL    TUMOURS. 

peritoneal  cavity.  This  makes  the  radical  treatment  of 
intestinal  cancer  a  matter  of  risk  and  difficulty.  In  many  cases 
the  difficulty  is  so  great  that,  except  in  very  favourable 
circumstances,  surgeons  prefer  to  adopt  simple  methods 
which  will  relieve  the  patient,  rather  than  complicated 
and  dangerous  proceedings,  with  the  hope  of  curing  the 
disease. 

The  palliative  measures  vary  with  the  situation  of  the 
cancer.  For  example,  when  it  attacks  the  pylorus,  excision  of 
the  pylorus  and  union  of  the  cut  edges  of  the  stomach  and 
duodenum  is  a  dangerous  and  difficult  procedure,  and 
applicable  to  such  a  small  proportion  of  cases  that  this 
practice  is  now  abandoned.  In  order  to  obviate  the  almost  in- 
evitable death  from  starvation,  a  fistula  is  sometimes  established 
between  the  stomach  and  jejunum.  This  method  of  gastro- 
intestinal anastomosis  has  in  a  few  cases  been  followed  by 
very  encouraging  results,  but  it  does  not  meet  with  general 
favour.  A  few  surgeons  not  only  advocate  gastro-intestinal 
anastomosis,  but  recommend  excision  of  the  cancerous  pylorus 
(pylorectomy)  in  favourable  cases.  These  methods  are  still 
upon  their  trial. 

Cancer  of  the  rectum  can  in  many  instances  be  easily  and 
freely  excised  (proctotomy).  A  ready  way  in  which  surgeons 
estimate  the  suitability  of  a  rectal  cancer  for  excision,  is  to 
introduce  the  index  finger  through  the  anus,  and  if  the  tip  of 
the  finger  passes  beyond  the  tumour  it  is  taken  as  an  indica- 
tion that,  so  far  as  implication  of  the  rectum  is  concerned, 
the  disease  admits  of  removal.  The  favourable  cases  are  those 
in  which  the  cancer  is  of  such  limited  extent  that  it  can  be 
circumscribed  by  the  finger,  is  mainly  limited  to  the  posterior 
Avail  of  the  gut,  and  does  not  involve  the  anus,  prostate,  or 
vagina,  according  to  the  sex.  When  rectal  cancer  is  too 
extensive  for  excision,  patients  are  often  rendered  comfortable 
by  inguinal  or  lumbar  colotomy.  The  routine  employment 
of  colotomy  for  every  case  of  rectal  cancer  that  cannot  be 
excised  is  to  be  deprecated. 

In  the  case  of  the  colon  various  methods  have  been 
advocated.  The  ideal  operation  consists  in  resection  of  the 
diseased  area  of  the  gut  and  sutural  union  of  the  cut  ends  so 
as  to  restore  the  continuity  of  the  intestine.     This  operation 


ADENOMA   AND   CARCINOMA.  271 

has  been  successfully  accoinplislied,*  but  it  is  very  tedious 
and  attended  by  an  excessively  high  mortality. 

It  is  much  safer  practice  to  resect  the  diseased  part  of  the 
colon  and  unite  the  edges  of  the  bowel  to  the  margins  of  the 
skin  incision  either  in  the  lorn  or  flank,  according  to  the  fancy 
of  the  operator.  This  mode,  introduced  by  Mr.  Bryantf  and 
known  as  colectomy,  is  of  very  limited  application,  as  it  depends 
entirely  on  the  position  and  freedom  of  the  tumour  from 
adhesions. 

The  third  method  is  to  perform  colotomy,  an  extremely 
simple  proceeding  when  the  position  of  the  cancer  can  be 
ascertained.  In  a  large  majority  of  cases  this  is  impossible. 
In  such  circumstances  the  most  judicious  proceeding  consists 
in  opening  the  abdomen  in  the  middle  line,  between  the 
umbilicus  and  the  pubes,  then  introducing  the  hand  for  the 
purpose  of  ascertaining  the  seat  of  the  cancer.  This  accom- 
plished, the  abdominal  wound  is  closed  and  an  artificial  anus 
established  in  the  right  or  left  loin  (or  in  the  flank),  according 
to  the  requirement  of  the  case. 

In  all  patients  that  come  under  my  care  with  intestinal 
obstruction,  supposed  to  depend  upon  cancer  of  the  colon,  and 
in  whom  no  tumour  can  be  localised  by  physical  signs, 
I  prefer  to  explore  the  intestines  through  an  abdominal 
incision,  and  then  perform  a  right  or  left  lumbar  colotomy  as 
the  case  demands. 

The  study  of  a  large  number  of  cases  indicates  that  life  is 
more  often  prolonged  after  colotomy  than  after  resection  of 
the  cancerous  gut,  or  colectomy,  whilst  the  risk  to  life  is 
enormously  diminished. 

It  is  also  a  fact  well  worth  bearing  in  mind  that  after  the 
pressure  upon  a  section  of  colon,  straitened  by  cancer,  is 
relieved  by  a  timely  colotomy,  the  obstruction  after  a  time 
partially  disappears  and  allows  fasces  once  more  to  pass  into 
the  distal  portion  of  the  gut.  Indeed  in  some  cases  the 
passage  through  the  cancerous  segment  becomes  so  free  that 
patients  allow  the  colotomy  opening  to  close. 

*  Kendal  Franks,  Med.-Chir.  Trans.,  vol.  Ixxii.  211  ;  and  Treves,  Cl'm.  Journal, 
vol.  i.  224. 

t  Med.-Cliir.  Trans.,  vol.  Ixv.  131;  Pitts,  Trans.  Clin.  Soc,  vol.  xx.  210. 


CHAPTER    XXVIII. 

ADENOMA  AND    CARCINOMA   OF    THE   UTERUS    AND 
FALLOPIAN    TUBES. 

From  an  anatomical  point  of  view  it  will  be  necessary  to  con- 
sider the  subject  of  epithelial  tumours  of  the  uterus  and  tubes 
in  three  sections  : — 

1.  Adenoma  and  carcinoma  of  the  cervical  canal. 

2.  Adenoma  and  carcinoma  of  the  body  of  the  uterus. 

3.  Adenoma  and  carcinoma  of  the  Fallopian  tube. 

This  arrangement  is  justified  on  the  grounds  that  the 
character  of  the  glands  differs  in  each  section.  Epithelioma 
of  the  vaginal  portion  of  the  cervix  has  been  already  con- 
sidered.    (Page  212). 

THE    CERVICAL   CANAL. 

Adenomata. — The  cervical  canal  is  lined  with  columnar 
epithelium  and  furnished  with  numerous  racemose  glands. 
Adenomata,  which  are  structurally  repetitions  of  these  glands, 
are  very  common  at  the  neck  of  the  uterus.  There  are  three 
varieties ;  sessile,  pedunculated  and  racemose  adenomata. 

A  sessile  Adenoma  appears  as  a  soft  velvety  areola  around 
the  OS ;  it  is  in  colour  like  a  ripe  strawberry,  and  thickly 
dotted  with  minute  spots  of  a  brighter  pink.  This  pink 
tissue  is  composed  of  glandular  acini  lined  with  large  regular 
columnar  epithelium.  The  glandular  tissue  often  extends 
beyond  the  margins  of  the  os  and  invades  the  vaginal  portion 
of  the  cervix.  Sometimes  it  is  so  abundant  that  the  apex  of 
the  cervix,  instead  of  being  a  cone,  assumes  rather  the  shape 
of  the  under  surface  of  a  mushroom.  The  glandular  mass  is 
not  confined  to  the  margins  of  the  os,  but  extends  for  a  variable 
distance  up  the  canal.  When  adenoma  affects  a  lacerated 
cervix  the  whole  of  the  exposed  portion  of  the  canal  is  in- 
volved. The  surface  of  a  sessile  adenoma  is  covered  with 
tenacious  mucus  secreted  by  the  abnormal  glands. 

Pedunculated  Adenomata  are  rarely  large ;  they  may  grow 
from  any  part  of  the  cervical  canal,  but  are  most  frequently 
found  springing  from  the  lower  2  cm.  of  the  canal.    As  a  rule. 


ADENOMA    AND    GAUGINOMA.  273 

they  occur  singly,  but  two  or  more  may  be  present.  They 
are  soft  and  velvety  to  the  touch,  and  are  dotted  with  minute 
pores.  Histologically,  they  consist  of  an  axis  of  fibrous  and 
sometimes  muscle  tissue,  covered  with  mucous  membrane 
continuous  with  that  lining  the  cervical  canal.  When  these 
pedunculated  adenomata  remain  within  the  canal,  the  epi- 
thelium covering  them,  and  the  glands  they  contain  are  of  the 
same  character  as  those  of  the  cervical  mucous  membrane. 
When  the  tumours  increase  in  size  and  project  into  the 
vagina,  the  epithelium  covering  the  protruding  portions 
becomes  stratified,  and  the  glands  disappear.  It  is  necessary 
to  avoid  confounding  myomata  of  the  uterine  cervix  with 
pedunculated  adenomata. 

Adenomata  of  the  sessile  and  pedunculated  kind  are  not 
confined  to  women,  but  occur  also  in  female  monkeys. 

Racemose  Adenoma.  —  This  rare  variety  of  tumour 
resembles  a  bunch  of  grapes  hanging  from  the  neck  of  the 
uterus ;  the  various  grape-like  bodies  or  "  berries  "  are  of  a 
bluish-red  colour  during  life.  When  seen  projecting  into  the 
vagina  the  appearance  is  not  unlike  that  of  a  h^^datid  mole 
protruding  from  the  uterus.  These  tumours  vary  in  size ; 
some  are  as  large  as  walnuts,  and  specimens  have  been  seen  as 
large  as  the  fist.  The  whole  of  the  vaginal  portion  of  the 
cervix  may  be  involved,  or  the  tumour  grows  from  a  limited 
area. 

In  many  of  the  cases  the  grape-like  bodies  have  thin 
translucent  walls,  and  resemble  the  cystic  projections  seen  on 
the  surface  of  a  pedunculated  rectal  adenoma ;  they  are  cysts 
lined  with  columnar  or  subcolumnar  epithelium  distended 
with  mucus.  When  the  tumour  is  very  rich  in  mucous 
glands  the  tumour  is  usually  covered  with  a  thick  layer  of 
tenacious  mucus.  The  surface  of  the  tumour  is  sometimes 
covered  with  stratified  epithelium  arranged  in  an  undulating 
manner,  continuous  with  that  covering  the  vaginal  surface  of 
the  neck  of  the  uterus. 

Carcinoma. — Cancer  may  begin  in  any  part  of  the  cervical 
canal,  but  it  appears  to  be  more  prone  to  affect  the  lower  than 
the  upper  half  Structurally  it  is  a  caricature  of  the  glands  of 
the  canal.  The  disease  spreads  rapidly  and  infiltrates  the 
connective  tissue  of  the  broad  lio'ament,  the  vesico-vasinal  and 


274  EPITHELIAL    TUMOURH. 

recto-vaginal  septa.  It  ulcerates  early  and  involves  that 
portion  of  the  cervix  projecting  into  the  vagina ;  later  it 
extends  to  the  lower  part  of  the  body  of  the  uterus;  and  in  the 
last  stages  of  the  disease  this  organ  becomes  completely 
hollowed  out  by  ulceration,  until  nothing  but  a  thin  layer  of 
muscle  tissue  covered  by  peritoneum  remains.  As  in  glan- 
dular carcinoma  in  general,  the  adjacent  lymph  glands  are 
quickly  implicated — tirst,  those  lying  in  the  course  of  the 
internal  iliac  artery,  and  then  the  lumbar  glands. 

Dissemination  is  frequent ;  secondary  deposits  occur  in  the 
liver  and  lungs.  Deposits  are  met  with  in  the  bones,  but  not 
with  the  same  frequency  as  in  mammary  cancer. 

Cancer  of  the  cervical  canal,  like  epithelioma  of  the  vaginal 
portion,  leads  to  perforation  of  the  anterior  and  posterior 
vaginal  septa,  so  that  urinary  and  fsecal  fistulee  complicate  the 
later  stages  of  the  disease. 

When  the  broad  ligaments  are  extensively  infiltrated  the 
ureters  become  involved ;  this  leads  to  dilatation  of  the  renal 
pelves.  As  cystitis  is  a  common  complication  of  carcinoma  of 
the  cervix  this,  in  conjunction  with  the  interference  with  the 
ureters,  serves  to  explain  the  almost  constant  presence  of 
suppurative  pyelitis  and  nephritis  found  during  post-mortem 
examinations  of  women  with  uterine  cancer.  A  very  large 
proportion  of  these  patients  exhibits  marked  ursemic 
symptoms  in  the  later  stages  of  their  lives. 

Among  other  complications  of  cancer  of  the  cervix, 
especially  when  it  extends  to  the  body  of  the  uterus,  must 
be  mentioned  pyo-salpinx  and  hydro-salpinx.  In  these  cases 
the  dilated  tubes  are  rarely  thicker  than  the  thumb,  but  they 
are  a  source  of  danger  inasmuch  as  perforation  occasionally 
occurs  and  sets  up  infective  peritonitis.  Exceptionally  the 
cancer  perforates  the  body  of  the  uterus.  When  this  happens 
peritonitis  may  ensue  and  quickly  cause  death ;  in  some  in- 
stances the  carcinomatous  material  becomes  distributed  over 
the  peritoneum,  and  small  knots  form  upon  the  serous  surfaces 
of  the  intestine,  liver,  spleen,  etc.  This  distribution  of  the 
cancer  may  lead  to  an  effusion  of  blood-stained  fluid  into 
the  belty,  sometimes  in  considerable  quantity,  or  to  aggluti- 
nation of  coils  of  intestine,  each  cancerous  nodule  being 
the  focus  of  a  limited  area  of  peritonitis.     Occasionally  actual 


ADENOMA    AND    GABGINOMA.  275 

perforation  of  the  uterus  is  prevented  by  a  piece  of  intestine 
becoming  adherent  to  the  uterus  at  the  spot  where  the  disease 
is  approaching  the  surface  :  adhesion  of  intestine  in  this  way 
may  take  place  between  the  uterus  and  small  intestine,  but  I 
have  several  times  found  the  transverse  colon  adherent  to  the 
uterine  fundus,  this  part  of  the  large  intestine  being  in  the 
form  of  the  omega-,  or  U-shaped  colon.  It  is  important  to  bear 
this  in  mind,  because  when  a  ftecal  fistula  complicates  cancer 
of  the  uterus  it  is  usually  attributed  to  a  communication  v/ith 
the  rectum  or  sigmoid  flexure,  and  these  are  the  common 
situations ;  but  in  some  cases  the  fistula  is  in  the  transverse 
colon. 

Cancer  of  the  cervix  uteri  is  very  common  between  forty 
and  fifty  ;  many  cases  occur  between  thirty  and  forty.  Before 
thirty  the  disease  is  rare,  but  I  have  observed  undoubted  cases 
in  women  of  twenty- throe,  tAventy-five,  and  twenty- six  years 
of  age. 

THE   BODY   OF  THE   UTERUS. 

Adenoma. — Innocent  glandular  tumours  of  the  uterine 
cavity,  to  judge  from  recorded  cases,  are  very  rare.  This  is 
probably  due  to  the  fact  that  adenomata  in  this  situation 
assume  the  form  of  uterine  polypi,  and  as  these  tumours  are 
rarely  submitted  to  histological  investigation  their  nature  is 
overlooked.  Adenomata  of  the  uterine  mucous  membrane 
are  pedunculated  tumours,  and  have  an  appearance  very 
similar  to  rectal  adenomata  ;  it  is  possible  that  on  this  account 
they  are  sometimes  described  as  mucous  polypi.  Micro- 
scopically these  tumours  consist  of  cystic  spaces  lined  with 
columnar  epithelium,  the  cavities  being  filled  with  mucus. 

Carcinoma. — Primary  cancer  of  the  body  of  the  uterus  is 
rare.  Histologically,  it  mimics  the  peculiar  tubular  glands 
which  exist  in  the  mucous  membrane  lining  the  uterine 
cavity.  Very  few  cases  of  this  affection  have  been  described, 
because  when  the  patients  come  under  observation  the  disease 
is  usually  regarded  as  some  form  of  endometritis  and  treated 
by  scraping  and  the  like. 

Of  the  early  stages  of  cancer  affecting  the  body  of  the 
uterus  nothing  is  known.  The  disease  remains  for  a  long  time 
restricted  to  the  cavity  of  the  uterus,  and  occasionally  creeps 


276  EPITHELIAL    TUMOURS. 

into  one  or  both  Fallopian  tubes ;  but  it  very  rarely  involves 
the  mucous  membrane  of  the  cervical  canal,  save  in  the  very 
late  stages,  and  after  it  has  extensively  destroyed  the  muscular 
substance  of  the  uterus.  It  is  also  apt  to  perforate  the  uterine 
wall  and  lead  to  adhesion  between  it  and  the  intestine. 

Cancer  of  the  body  of  the  uterus  is  rare  before  the  age 
of  forty-five  ;  it  is  most  frequent  at,  or  subsequent  to,  the 
menopause.  Most  of  the  cases  occur  between  the  fiftieth 
and  seventieth  years. 

The  signs  that  usually  attract  attention  are  the  occurrence 
of  fitful  haemorrhages  after  the  menopause,  followed  by 
profuse  and  often  offensive  discharges  of  purulent  material 
from  the  uterus. 

THE    FALLOPIAN    TUBE. 

Adenoma. — The  Fallopian  tube  is  a  rare  locality  for  an 
adenoma,  but  a  few  examples  are  known,  and  these  present 
some  interesting  features. 

The  tumour  takes  the  form  of  papillomatous-like  masses 
sprouting  from  the  mucous  membrane  and  distending  the 
tube.  The  processes  may  have  a  dendritic  appearance,  or 
assume  the  form  of  grape-like  masses,  resembling  somewhat 
the  curious  condition  known  as  hydatid  mole. 

Microscopically  these  tumours  contain  glandular  recesses 
lined  with  columnar  epithelium  ;  the  disposition  of  the  parts 
resembles  the  recesses  of  the  tubal  mucous  membrane. 

A  curious  clinical  feature  associated  with  these  tumours 
is  the  occurrence  of  hydroperitoneum,  due  to  the  fact  that 
the  presence  of  an  adenoma  in  the  tube  does  not  lead  to 
occlusion  of  its  ostium,  hence  the  secretion  from  the  tube 
leaks  into  the  peritoneum  and  leads  to  an  effusion  of  fluid.* 

Carcinoma. — Primary  cancer  of  the  Fallopian  tube  is  an 
excessively  rare  affection — so  rare,  indeed,  that  there  is  little 
reliable  evidence  forthcoming  concerning  it.  As  yet  it  is 
impossible  to  write  a  general  account  of  the  disease  either 
from  a  clinical  or  pathological  point  of  view.  Occasionally 
cancer  originating  in  the  mucous  membrane  of  the  cavity  of 
the  uterus  will  invade  the  tubes,  and  it  is   possible  that  a 

*  For  further  details  of  adenoma  of  the  tube  my  book  on  "  Diseases  of  the 
Ovary  and  Tubes  "  may  be  consulted. 


ADENOMA    AND    CARCINOMA.  277 

primary  carcinoma  of  the  tube  would  extend  to  the  uterine 
mucous  membrane  ;  but  of  this  we  liave  no  evidence.  In  the 
meantime,  as  an  example  of  the  method  in  which  suspected 
cases  should  be  investigated,  reference  may  be  made  to  Doran's 
able  account  of  a  probable  case  of  primary  cancer  of  the 
Fallopian  tube.* 

Treatment. — The  most  satisfactory  method  of  dealing 
with  adenoma  (erosion)  of  the  neck  of  the  uterus,  consists  in 
slightly  dilating  the  canal  and  removing  the  adenomatous 
tissue  with  a  sharp  scoop  or  a  curette,  and  then  carefully 
searing  the  surface  with  Paquelin's  cautery.  This  simple 
treatment  is  effectual  when  adenoma  complicates  a  lacerated 
cervix,  and  is  often  as  satisfactory  as  the  operation  known  as 
trachelorraphy. 

Carcinoma. — A  study  of  the  pathological  tendencies  of 
uterine  cancer  is  of  the  first  importance  as  a  prelude  to 
its  treatment,  because  it  would  certainly  be  inferred  from 
experience  acquired  in  the  treatment  of  mammary  cancer  that 
if  it  be  desirable  to  remove  a  cancerous  uterine  cervix,  the 
interests  of  the  patient  would  be  best  served  by  the  entire 
removal  of  the  uterus. 

Dr.  Williamsf  has  clearly  pointed  out  that  the  tendency 
of  cancer  of  the  cervix,  in  its  early  stages,  is  to  infiltrate  the 
parametric  tissue  rather  than  to  extend  upwards  and  invade 
the  body  of  the  uterus.  Cases  are  occasionally  observed  in 
which  the  disease  even  in  its  early  stages  involves  the  body 
of  the  uterus,  but  these  are  exceptional. 

The  great  difficulty  in  the  operative  treatment  of  uterine 
ca,ncer  lies  in  the  circumstance  that  the  disease  is  so  insidious, 
and  in  the  majority  of  patients,  has  involved  the  tissues  so 
extensively  before  the  cases  come  under  observation,  that  an 
operation  for  the  adequate  removal  of  the  disease  is  attended 
with  so  much  immediate  danger,  while  the  probability  of  pro- 
longing life  is  so  very  remote  that  few  surgeons  are  disposed 
to  urge  such  measures  upon  their  patients. 

The  important  question  to  decide  in  the  treatment  of 
cancer  involving  the  cervical  canal  is  this  : —  When  the  disease 
is  recognised  early,  and  whilst  still  limited  to  the  cervix,  is  it 

*  Trans.  Path.  Soc,  vol.  xxxix.  208,  and  vol.  xl.  221. 
f  "  Cancer  of  the  Uterus." 


278  EPITHELIAL    TUMOURS. 

sufficient  to  a^nputate  the  cervix  only,  or  slioidd  the  wJiole 
uterus  be  extirpated  f 

Dr.  J.  Williams  is  very  emphatic  in  the  opinion  that  in 
such  cases  the  removal  of  the  cervix  is  sufficient,  and  a  study 
of  the  arguments  he  adduces  would  appear  to  establish  this. 
The  view  has  been  severely  criticised  by  a  few  obstetric 
physicians  who  maintain  that  the  whole  uterus  should  be 
extirpated. 

Published  statistics  relating  to  this  matter  indicate  that 
when  it  is  possible  to  remove  the  disease  completely  by  limit- 
ing the  operation  to  the  cervix  it  is  the  safer  measure,  and 
offers  a  good  prospect  to  the  patient,  the  risk  to  life,  so  far  as 
the  operation  is  concerned,  being  reduced  to  a  minimum. 

The  rules  for  the  treatment  of  uterine  cancer  may  be 
formulated  thus : — 

1.  Amputation  of  the  vaginal  segment  is  sufficient  when 

the  cancer  is  limited  to  the  lower  portion  of  the  cervix. 

2.  When  the  cancer  has  extended  to  the  upper  segment 

of  the  cervical  canal  it  will  be  necessary  to  perform 
supra-vaginal  amputation  of  the  cervix. 
In  primary  cancer  of  the  body  of  the  uterus  the  whole 
organ  should  be  removed  through  the  vagina. 

When  the  cancerous  ulceration  has  extended  beyond  the 
uterine  tissues  operative  interference  is  worse  than  useless. 


279 

CHAPTER    XXIX. 

GROUP    III. -DERMOIDS. 

Dermoids    are    tumours    furnislied    with    skin    or    mucous 
membrane  occurring  in  situations  where  these  structures  are 
not  found  under  normal  conditions.     They  only  possess  tissues 
which  naturally  belong  to  skin  or  mucous  membrane. 
Dermoids  may  be  arranged  in  four  genera : — 
I.  Sequestration  dermoids. 
II.  Tubulo-clermoids. 

III.  Ovarian  dermoids. 

IV.  Dermoid  patches. 

Each  genus  contains  at  least  two  species  that  occur  in 
definite  situations  and  present  structural  peculiarities.  The 
simplest  dermoids  belong  to  the  first  genus,  the  most  complex 
are  found  in  the  ovary. 

SEQUESTRATION   DERMOIDS. 

Dermoids  belonging  to  this  genus  arise  in  detached  or 
sequestrated  portions  of  surface  epithelium,  chiefly  in  situa- 
tions where,  during  embryonic  life,  coalescence  takes  place 
between  skin-covered  surfaces. 

Dermoids  of  the  Trunk. — These  occur  strictly  in  the 
regions  where  the  lateral  halves  of  the  body  coalesce.  This 
line  of  union,  commencing  immediately  below  the  occipital  pro- 
tuberance, extends  along  the  middle  of  the  back  to  the  coccyx ; 
it  then  passes  through  the  perineum  (scrotum  and  penis  in 
the  male)  and  upwards  through  the  umbilicus,  thorax,  neck 
and  chin,  to  terminate  at  the  margin  of  the  lower  lip. 

Dermoids  are  rare  along  the  dorsal  part  of  this  line,  and 
when  they  do  occur  are  apt  to  be  mistaken  for  spina  bifida 
cysts.  In  at  least  one  instance  a  dermoid  has  been  detected 
in  association  with  spina  bifida  occulta.  The  parts  are  shown 
in  section  in  Fig.  123.  The  patient  was  a  child  two  years  old  ; 
the  skin  covering  the  defective  spines  presented  the  hair-field 
usual  in  these  cases.  In  the  tissues  immediately  over  the 
stunted  spines  there  was  a  dermoid  containing  the  usual 
pultaceous  material  and  hairs.    The  specimen  was  dissected  by 


280 


DERMOIDS. 


Mr.  Gilbert  Barling,  who  kindly  afforded  mc  an  opportunity 


of  examining  it. 


Theoretically,  dermoids  should  occur  with  tolerable 
frequency  along  the  mid-dorsal  line.  In  a  case  described  by 
Dr.  Wild*  (which  I  had  an  opportunity  of  examining),  a 
large  dermoid  projected  from  the  lumbo-sacral  region  of  a 
man  aged  twenty-two  years.  It  was  congenital,  and  had  been 
regarded  as  a  spina  bifida  cyst.  The  swelling  had  never 
caused  the  man  inconvenience  until  a  few  days  before  his 
admission  into  hospital,  when  it  became  inflamed  and  then 

burst,  discharging  a  quantity 
of  foul-smelling  sebaceous  ma- 
terial mixed  with  hairs.  The 
cavity  was  freely  opened  and 
cleared  of  decomposing  ma- 
terial. The  skin  lining  the 
interior  of  the  dermoid  was 
beset  with  pores  of  large  size, 
corresponding  to  the  orifices  of 
sweat  glands  ;  when  the  patient 
perspired,  drops  of  sweat  could 
be  seen  oozing  from  these  pores. 
This  skin  also  contained 
nerves,  for  the  man  could 
localise  the  prick  of  a  pin  on  the  interior  of  the  dermoid,  as 
easily  as  one  made  upon  the  skin  surrounding  the  tumour. 
When  the  tumour  was  removed,  the  spinous  processes  under- 
lying it  were  found  to  be  unusually  short  and  surrounded  by 
fat.     (Fig.  124.) 

Faulty  coalescence  of  the  cutaneous  covering  of  the  back 
often  occurs  over  the  lower  sacral  vertebrae,  and  gives  rise  to 
small  congenital  sinuses  knowm  as  "  post-anal  dimples."  These 
recesses  are  lined  with  skin  furnished  with  hairs,  sebaceous 
and  sweat  glands.  Sometimes  they  measure  10  mm.  in  depth. 
As  a  rule,  they  are  single  and  often  accompany  lumbo-sacral 
spina  bifida.  Though  most  commonly  seen  over  the  coccy- 
geal, or  the  last  two  sacral  vertebrse,  I  have  seen  them  as  high 
as  the  fourth  lumbar  vertebra,  and  always  exactly  in  the 
middle  line. 

*  Trans.  Path.  Soc,  vol.  xl.,  p.  386. 


Fig.  123. — Section  of  three  thoracic  vertebrae 
with  a  small  dermoid  situated  over  two 
stunted  spinous  processes. 


SEQUESTRATION   DERMOIDS.  281 

These  post-anal  dimples  are  interesting,  for — as  will  be 
shown  afterwards — in  many  situations  where  sequestration 
dermoids  occur,  similar  cutaneous  recesses  are  also  seen.  An 
examination  of  such  a  sinus  serves  to  show  that  if  its  external 
orifice  became  occluded,  without  the  deeper  parts  becoming 
obliterated,  we  should  have  the  germ  of  a  dermoid,  for  the 
numerous   glands .  in    the   walls   would  be   active,  and  their 


tJi 


-    i7 

Fig.  ]24. — Dermoid  in  tlie  lumbo-sacral  regiou  of  a  man  twenty-two  years  of  age. 

secretion,  with  the  shed  epithelial  scales  and  hairs,  would  soon 
cause  it  to  enlarge  and  assume  such  proportions  as  to  be 
clinically  recognised  as  a  tumour. 

A  good  physiological  type  of  such  dermoids  is  furnished 
by  the  interdigital  pouch  of  the  sheep.  This  pouch — as 
shown  in  Fig.  125— lies  between  the  digits,  and  all  the  dis- 
section required  to  expose  it  is  to  separate  the  digits  with  a 
sharp  knife,  keeping  close  to  the  phalanges  of  one  or  other 
side.  In  adult  sheep  it  is  always  full  of  shed  wool  and  grit. 
Sometimes  its  orifice  is  occluded  and  it  becomes  a  retention 
cyst ;  suppuration  follows,  much  to  the  sheep's  discomfort. 


282 


DERMOIDS. 


The  walls  of  this  pouch  are  full  of  very  large  glands.  In 
order  to  get  satisfactory  sections  it  is  necessary  to  obtain  the 
digits  from  a  still-born  lamb,  for  as  soon  as  lambs  run  about 
grit  gets  into  the  pouch  and  spoils  the  edge  of  the  knife. 

Dermoids  of  the  Scrotum. — There  are  many  good  reasons 
for  believing  that  the  majority  of  dermoids  reported  as  arising 
in  the  testicles  were  really  scrotal  in  origin.     This  was  clearly 

the  case  in  a  specimen  described 
by  Bilton  Pollard*  as  a  dermoid 
of  the  testicle.  The  dermoid 
was  situated  on  the  left  side  of 
the  scrotum,  between  the  testi- 
cles, and  adhered  to  the  back  of 
the  left  one  outside  the  tunica 
vaginalis.  It  contained  putty- 
like material  in  which  there 
were  a  few  grey  hairs.  The 
cyst  was  lined  with  stratified 
epithelium;  papillse  and  seba- 
ceous glands  were  detected. 

It  is  usually  stated  in  text- 
books that  dermoids  of  the 
testis  are  common.  This  is 
very  improbable,  for  very  few 
cases  are  to  be  found  in  surgi- 
cal literature,  and  the  details 
in  most  cases  are  insufficient  to  enable  me  to  determine 
whether  the  dermoids  were  scrotal  or  testicular.  For  evidence 
as  to  the  rarity  of  testicular  dermoids  Mr.  D'Arcy  Power's  f 
paper  should  be  consulted.  In  records  of  future  cases  it 
will  be  necessary  to  pay  particular  attention  to  the  relation 
the  dermoids  bear  to  the  testicle,  tunica  vaginalis,  and 
scrotum. 

Dermoids  have  been  found  in  the  inguinal  canals  of 
men  closely  associated  with  the  spermatic  cord,  and  it  may 
be  easily  imagined  that  in  such  situations  they  run  the 
risk  of  being  confounded  with  hernise.  Such  specimens  are 
excessively  rare,  and  as  I  have  not  had  an  opportunity  of 

*  Trans.  Path.  Soc,  vol.  xxxvii:,  p.  342. 
f  Trans.  Path.  Soc,  vol.  xxxviii.,  p.  242. 


Fig.  125. — Median  aspect  of  a  sheep's  digit, 
showing  the  interdigital  povich. 


SEQUESTRATION  DERMOIDS. 


283 


Judging  from  tlie  few  available 


investigating  one,  I  am  unable  to  otter  an  explanation  of  their 
mode  of  origin. 

Dermoids  of  the  Thorax 
records,  dermoids  of  the  thorax  are  very  uncommon.  They 
occur  in  two  situations — viz.,  on  the  anterior  aspect  of  the 
sternum  and  in  the  thoracic  cavity.  Dermoids  on  the  front  of 
the  sternum,  are  situated  in  the  middle  line  near  the  junction 


?JT,BALC0M3\S  = 


Fig.  126. — Dermoid  situated  over  the  junction  of  the  manubrium  and  gladiolus  of  the 
sternum  ;  there  was  also  a  dermoid  near  the  left  cornu  of  the  hyoid  bone.  The  boy  was 
nineteen  years  of  age.    {After  Bramann.*) 


of  the  manubrium  with  the  gladiolus.  (Figs.  126  and  127.) 
Cahen's  f  patient  was  a  child  eight  months  old.  The  mother 
stated  that  at  birth  the  tumour  was  no  larger  than  a  pea,  but 
had  slowly  increased  in  size.  It  was  extirpated,  and  found  to 
contain  sebaceous  material ;  the  wall  of  the  cyst  was  lined  with 

*  Langenbeck's  "  Archiv,"  bd.  xl. 
f  Zeitschrift  fiir  Chir.,  bd.  xsxi.  370. 


284 


DERMOIDS. 


stratified  epithelium,  and  it  contained  sweat-glands.  Glutton* 
described  a  specimen  which  he  removed  from  a  female  thirty- 
nine  years  of  age.  The  tumour  contained  eleven  ounces  of 
pultaceous  material.  The  wall  of  the  cyst  was  lined  with  skin, 
and  one  hair  was  found  growing  from  it.  No  glands  were 
detected.  When  the  patient  was  six  weeks  old  the  tumour 
was  as  big  as  a  pea :  at  the  age  of  nineteen  it  had  attained 


Fig.  127. — Prestemal  dermoid.     {After  Cahen.) 

the  dimensions  of  an  egg,  and- continued  slowly  to  increase  in 
size.  When  the  patient  came  under  Glutton's  care  the  tumour 
hung  pendulous  between  the  breasts.  The  history  of  the  case 
clearly  indicated  that  the  dermoid  had  been  from  the  first 
situated  over  the  middle  of  the  sternum. 

Intrathoracic  dermoids  seem  to  be  equally  rare.  Hale 
White  f  met  with  one  as  large  as  a  Tangerine  orange,  attached 
to  the  anterior  and  right  surface  of  the  pericardium,  and  by  a 
few  adhesions  to  the  right  lung.  The  cyst  contained  sebaceous 
matter  and  hair. 

*  Trans.  Path.  Soc,  vol.  xxxviii.  393. 
t  Trans.  Path.  Soc,  vol.  xli.  283. 


SE  Q  UES  TBA  TION   DERMOIDS. 


285 


Albers*  described  and  figured  a  dermoid  of  the  thorax 
that  occurred  in  a  woman  twenty-eight  years  old.  At  the 
age  of  fifteen  it  was  noticed  she  brought  up  hairs  on  coughing. 
At  her  death  a  large  cyst,  furnished  with  pilose  skin  and 
fleshy  protuberances,  was  found  in  connection  with  the  left 
lung. 

A  case  fully  reported  in  regard  to  clinical  details  by  Dr. 
Douglas  Powell  and  Mr.   Godleef   Avas   observed   in   a   lady 


Fig.  12S.— Sternal  dimple.     {After  W.  W.  Ord.) 


twenty-nine  years  of  age.  She  presented  signs  of  empyema, 
and  whilst  under  operative  treatment  it  was  ascertained  that  a 
large  dermoid  occupied  the  right  pleura  and  extended  to  the 
summit  of  the  lung.  The  interior  of  the  dermoid  contained 
hair  and  fleshy  protuberances  as  in  Albers'  case.  The  patient 
died  four  years  after  the  cyst  had  been  opened,  but  no  post- 
mortem examination  could  be  obtained.  In  this  case  the 
cyst  communicated  with  a  bronchus,  because  the  patient 
remembered  that  she  had  coughed  up  hair. 

*  Atlas  der  Path.  Anat.,  1846,  tab.  xxxiv.;  und  Erlauterung,  s.  342. 
t  Med.-Chir.  Trans.,  vol.  Ixxii.  317. 


286  DERMOIDS. 

At  first  glance  it  would  seem  difficult  to  account  for  the 
presence  of  a  large  dermoid  within  the  thorax,  and  it  has  been 
thought  that,  as  dermoids  are  not  uncommon  at  the  episternal 
notch,  a  cj^st  in  this  situation  had  burrowed  downwards  into 
the  superior  mediastinum  and  encroached  upon  the  pleura.  A 
review  of  the  mode  of  development  of  the  sternum  throws 
much  clear  light  on  the  subject.  The  two  lateral  halves  of 
the  sternum  are,  in  the  early  embryo,  widely  separated  from 
each  other ;  gradually  they  coalesce  in  the  middle  line.  Every 
anatomist  is  aware  that  this  median  coalescence  is  extremely 
liable  to  be  faulty,  and  conditions  occur  like  those  which,  hap- 
pening in  connection  with  the  medullary  folds,  produce  spina 
bifida.  In  this  line  of  coalescence,  so  far  as  sternal  dermoids 
are  concerned,  we  may  get  skin-lined  recesses  resembling  the 
coccygeal  dimples  (Fig.  128).  These  sternal  recesses,  or 
dimples,  occur  near  the  junction  of  the  manubrium  with  the 
gladiolus,  and  may  be  more  than  a  centimetre  deep.  Should 
a  piece  of  skin  become  sequestrated  during  coalescence  of  the 
thoracic  walls,  it  may,  during  the  development  of  the  sternum, 
be  dislocated  forwards  to  the  outer  surface,  or  backwards 
towards  the  mediastinum,  conditions  in  every  way  parallel  to 
the  variations  in  the  position  of  cranial  dermoids.  So  long  as  a 
dermoid  on  the  deep  surface  of  the  sternum  remains  small  it 
will  cause  no  trouble,  but  it  is  easy  to  understand  that  a 
large  tumour,  as  in  Glutton's  patient,  would,  if  projecting  into 
the  thorax,  encroach  on  the  plqura;  even  then  it  would 
not  nroduce  much  disturbance  so  Ions:  as  air  did  not  afain 
access  to  it ;  but  if  by  pressure  the  wall  of  the  cyst  becomes  so 
thin  as  to  allow  air  to  enter  its  cavity,  or  an  actual  communi- 
cation forms  between  the  cyst  and  a  bronchus  or  the  air- 
sacs  of  the  lung,  then  suppuration,  with  all  its  disastrous 
consequences  would  ensue. 


287 


CHAPTER     XXX. 

SEQUESTRATION  DERMOIDS  (continued). 

Facial  Dermoids. — Dermoids  occur  on  the  face  in  certain 
definite  positions,  such  as  the  inner  and  outer  angles  of  the 
orbit ;  the  upper  eyehd:  in  the  naso-facial  sulcus;  on  the  cheek 
slightly  posterior  to  the  angle  of  the  mouth ;  in  the  middle 
line  of  the  chin,  and  on  the  nose.  To  these,  for  the  sake  of 
convenience  in  description,  may  be 
added  dermoids  of  the  palate. 

In  order  to  appreciate  the  origin 
of  dermoids  in  these  situations  it  is 
necessary  to  bear  in  mind  the  relation 
of  the  facial  fissures  in  the  embryo, 
which  in  the  adult  are  represented 
by  the  orbits,  lachrymal  ducts,  mouth, 
and  certain  furrows  in  the  lips  and 
cheek. 

In  the  early  embryo  the  central 
portion  of  the  face  is  represented  by 
an  opening  from  which  five  fissures 
radiate.  The  upper  pair  (Fig.  129)  are 
the  orbito-nasal ;  the  two  lower  fissures 
are  termed  mandibular,  and  a  fifth,  not 
shown  in  the  figure,  the  intermandibular  fissure.  The  median 
fold  projecting  into  the  opening  from  above  is  the  fronto- 
nasal process,  which  ultimately  forms  the  nose.  As  it 
develops,  a  rounded  prominence  known  as  the  globular 
process,  forms  at  each  angle  and  gives  rise  to  a  portion  of  the 
ala  of  the  nostril  and  the  corresponding  premaxilla.  These 
globular  processes  fuse  together  in  the  middle  line  to  form  the 
central  piece,  or  philtrum,  of  the  upper  lip.  The  elongation 
of  the  fronto-nasal  process  necessarily  lengthens  the  orbito- 
nasal fissures.  Eventually  the  sides  of  the  fronto-nasal  plate 
coalesce  superficially  with  the  maxillary  processes  in  such  a 
way  as  to  leave  a  cleft  on  each  side,  which  becomes  the  orbit, 
the  line  of  union  being  permanently  indicated  in  the  adult  by 
the  naso-facial  sulcus  or  groove,  and  indicated  still  more  deeply 


Fig.  129. — Head  of  an  early 
human  embryo,  showing 
the  disposition  of  the  fa- 
cial fissures.  (After  His.) 


288 


DERMOIDS. 


by  the  lachrymal  duct,  which  is  a  persistent  portion  of  the 
original  orbito-nasal  fissure.  The  union  of  the  fronto-nasal 
plate  with  the  maxillary  processes  completes  the  nose, 
cheeks,  and  upper  lip. 

The  above  account  indicates  in  a  general  way  the  relation 
of  these  fissures  to  each  other ;  but  it  will  be  necessary  in  con- 
sidering dermoids  arising  in  them  to  mention  certain  details 
connected  with  each.    But  here  it  may  be  mentioned  that  the 


Fia;.  130. — Mandibular  tubercle  associated  with  a  malformed  auricle. 


defects  associated  with  any  of  them  are  of  three  kinds: — 
1,  the  fissure  may  persist;  2,  it  may  close  imperfectly  and 
leave  a  recess  or  puckering  of  the  skin ;  3,  portions  of  the 
surface  epithelium  may  be  sequestrated  and  give  rise  to 
dermoids. 

These  conditions  may  be  illustrated  by  the  mandibular 
fissure.  In  the  embryo  this  fissure  or  cleft  is  relatively  more 
extensive  than  the  opening  of  the  mouth  which  in  the  adult 
ultimately  represents  it.  In  fishes  the  whole  of  the  mandibular 
fissure  persists  as  the  gape  ;  but  in  mammals  the  dorsal  portions 
of  the  clefts  are  obliterated  by  the  union  of  their  margins, 
leaving  the  central  portion  as  the  mouth.  Persistence  of  the 
whole  length  of  the  fissure  is  a  rare  defect,  and  known  as 
macrostoma.  Excessive  closure  of  the  fissure  produces 
microstoma.    Imperfect  union  of  those  sections  that  normally 


SEQUESTRATION  DERMOIDS. 


289 


coalesce  gives  rise  to  slighter  imperfections,  of  wliich  some 
examples  will  now  be  described. 

Occasionally  we  find  on  one  or  both  cheeks  of  children,  at 
a  spot  varying  from  2  to  4  cm.  behind  the  angle  of  the  mouth, 
a  small  nodule  rarely  exceeding  a  rape-seed  in  size.  Some- 
times there  is  a  depression  or  sinus  in  the  cheek  surmounted 


Pig.  131. — Right  side  of  the  head  of  a  foetus,  showing  a  large  mandibular  tubercle  and  an 
accessory  tragus. 

by  the  nodule.  In  a  fair  proportion  of  cases  the  buccal 
mucous  membrane  presents  a  shallow  recess,  sometimes  a  sinus, 
and  occasionally  a  white  cicatrix  at  a  spot  exactly  correspond- 
ing to  the  nodule  on  the  cutaneous  surface  of  the  cheek. 

These  mandibular  tubercles  and  recesses  are  frequently 
associated  with  malformations  of  the  corresponding  auricles. 
(Fig.  130.) 

Mr.  Cowell  described  a  case  in  which  a  mandibular  tubercle 
was  associated  with  a  puckered  recess  in  the  mucous  mem- 
brane of  the  cheek,  two    cutaneous  tubercles  on  the  tragus 

T 


290 


DERMOIDS. 


of  the  corresponding  auricle,  and  a  coloboina  of  the  upper 
eyehd.  (Fig.  179.)  The  largest  specimen  which  has  yet  come 
under  my  observation  occurred  in  a  still-born  fVetus.  Pro- 
jecting from  the  right  cheek,  2  cm.  behind  the  angle  of  the 
mouth,  was  a  nodule  the  size  of  a  rape-seed,  and  immediately 
behind  this  a  pedunculated  body  8  mm.  long.  On  the  cor- 
responding pinna  there  was  an  accessory  tragus.  (Fig- 131.) 
Histologically  the  tubercle  on  the  cheek  consisted  of  dense 


Fig.  132. — Pierrot's  head,  to  show  the  mandibular  tubercle. 

connective  tissue  traversed  by  blood-vessels  and  covered  with 
skin  beset  with  lanugo,  and  richly  supplied  with  sweat  glands 
and  sebaceous  glands  of  large  size.  Thus  it  was  structurally 
a  small  dermoid  tumour.  The  left  cheek  and  pinna  were 
normal.  The  foetus  had  a  large  spina  bifida  sac  (meningo- 
myelocele) in  the  lumbar  region. 

In  connection  with  these  tubercles  it  will  be  interesting  to 
mention  that  Mr.  Noble  Smith  drew  my  attention  to  a  bronze 
bust  in  the  Art  Gallery,  Birmingham,  labelled  "Bust  of 
GoBcilius  Jucunchis,  a  money  lender.  Bronze.  The  original 
found  in  Pompeii,  and  now  in  the  National  Museum, 
Naples."  Behind  the  angle  of  the  mouth  on  the  left  cheek 
there  is  a  well-marked  mandibular  tubercle. 


SEQUESTRATION  DERMOIDS. 


291 


It  may  here  be  pointed  out  that  m  many  mammals, 
especially  dogs,  small  cutaneous  nodules  furnished  with 
vibriss^e  may  often  be  detected  in  a  line  Avith  the  angle  of 
the  mouth.     These  nodules  occupy  |)ositions  identical  with 


Fig.  133.— Median  Assure  of  the  lower  lip.     (IVolfler.) 


the  mandibular  tubercles  when  they   occur   on   the   cheeks 
of  children.     (Fig.  132.) 

There  is  very  little  relationship  between  pathology  and 
poetry,  but  that  very  philosophical  pathologist,  Dr.  Samuel 
Wilks,  in  reference  to  my  observation  that  the  usual  position 
of  the  mandibular  tubercle  and  recess  corresponds  with 
that  of  the  dimjjle  in  the  baby's  cheek,  drew  my  attention 
to  the  following  passage  in  his  Harveian  Oration,  1879. 
"  From  any  point  of  view  we  take,  and  upon  whatever 
subject  we  fix  our  gaze,  we  come  to  the  conclusion  that 
the  greatest  discovery  ever  made  by  man  about  himself,  and 


292 


DERMOIDS'. 


of  the  earth  of  which  he  forms  a  part,  is   the  doctrine  of 
evokition." 

"  The  softest  dimple  iu  a  baby's  smile 
Springs  from  the  whole  of  past  eternity, 
Tasked  all  the  sum  of  things  to  bring  it  there." 

Wilks  observed  to  me  how  Httle  the  poet  (Miss  Bevington) 
divined  that  there  is  a  material  basis  for  these  three  pretty 
and  significant  hnes. 

Similar   defects   are   met   with   in   the   intermandibular 


Fig.  134. — Congenital  fistuliB  in  the  lower  lip  of  a  child,  associated  with  double  hare-lip. 
(After  Madelung.) 

fissure.  Thus,  when  the  mandibular  processes  fail  to  coalesce, 
the  result  will  be  a  median  cleft  in  the  lower  lip  extending  to 
or  even  beyond  the  chin.  (Fig.  133.)  Median  clefts  of  this 
kind  are  excessively  rare.  Occasionally  such  a  defect  is 
associated  with  a  dermoid*  or  a  pair  of  small  nodules  in  the 
skin.  In  terriers  such  nodules  are  almost  constantly  present 
between  the  symphysis  and  the  body  of  the  hyoid  bone. 
In  children  with  double  hare-lip  two  sinuses  are  sometimes 
seen  in  the  mucous  membrane  of  the  lower  lip.  Their  orifices 
are  indicated  by  small  but  prominent  papillae.  The  sinuses 
are  large  enough  to  admit  a  probe,  and  they  are  in  some  cases 
2  cm.  deep.  Mucoid  fluid  exudes  from  these  recesses,  it 
is   furnished  by  mucous  glands  which  beset  the  membrane 

*  Lannelongue,  "  Kystes  Congenitaux,"  1886,  p.  46. 


SEQUESTRATION  DERMOIDS.  293 

lining  their  walls.  Several  examples  of  this  condition  have 
been  recorded,  and  a  good  specimen  observed  and  described 
by  Madelung  is  represented  in  Fig.  134.  In  this  case  the 
child  was  the  subject  of  double  hare-lip  and  cleft  palate.  The 
two  conditions  seem  to  be  frequently  associated.  Madelung's 
patient  died  four  days  after  operation ;  the  lower  lip  was 
examined  microscopically,  and  some  excellent  drawings  illus- 
trating the  relations  of  the  glands  to  the  sinuses  accompany 
the  paper.* 

Arbuthnot  Lanef  reported  a  case  of  this  nature  in  a  lad 
thirteen  years  of  age  with  double  hare-lip. 

I  have  little  doubt  that  these  sinuses  are  due  to  faulty 


Fig.  135.— Hare-lip  in  a  frog,  associated  with  a  persistent  intermandibular  fissure. 
The  forelimbs  are  webbed. 

closure  of  the  intermandibular  fissure ;  this  view  of  their 
origin  is  strengthened  by  an  observation  of  Feurer,|  in  which 
he  detected  in  the  upper  lip  of  a  lad,  twenty  years  old,  a 
similar  sinus  on  the  right  side  of  the  philtrum ;  it  corre- 
sponded exactly  to  the  termination  of  the  naso-facial  fissure, 
i.e.,  exactly  in  the  line  of  a  right-sided  hare-lip. 

Dermoids  of  the  Orbito-nasal  Fissure, — Dermoids  appear 
in  the  course  of  this  fissure  in  three  definite  situations.  Of 
these,  by  far  the  most  frequent  is  the  outer  angle  of  the 
orbit,  where  they  form  rounded  tumours,  rarely  exceeding  the 
dimensions  of  a  cherry;  they  lie  in  close  relationship  with 
the  pericranium  covering  the  frontal  bone,  which  is  often 
deeply  hollowed  to  accommodate  them.     Dermoids  in  this 

*  Langenteck's  "  Archiv,"  bd.  xxxvii.,  s.  271. 
t  Clin.  Soc.  Trans.,  vol.  xxiv.,  p.  230. 
J  Langenbeck's  "  Archiv,"  bd.  xlvi.  35. 


294 


DERMOIDS. 


region  vary  somewhat  in  regard  to  their  position ;  sometimes 
they  are  quite  close  to  the  external  angular  process  of  the 
frontal  bone,  or  they  may  be  2  cm.  or  more  posterior  to  it 
(Fig.  136) ;  exceptionally  they  are  on  a  level  with,  or  even  lie 
beneath,  the  eyebrow. 

Dermoids  at  the  inner  angle  are  far  less  frequent.  Of  this 
the  example  given  in  Fig.  137  was  observed  in  a  middle-aged 
man.     In  this  situation  the  tumour  may  extend  beyond  the 


Fie.  136. — Dermoid  at  the  outer  angle  of  the  orbit. 


bone  and  lie  in  intimate  relation  with  the  dura  mater.  It  is  very 
necessary  to  remember  this  in  attempting  the  extirpation  of 
the  dermoid.  In  some  cases  the  tumour  may  have  a  peduncle 
continuous  with  the  dura  mater.  Under  such  conditions  the 
dermoid  may  transmit  the  cerebral  pulsation ;  it  is  then  apt  to 
be  mistaken  for  a  meningocele.  This  is  a  less  serious  error 
than  mistaking  a  meningocele  for  a  dermoid  and  following  up 
the  error  by  attempting  its  extirpation. 

In  addition  to  dermoids  at  the  orbital  angles,  they  some- 
times occur  in  the  tissues  of  the  upper  eyelid,  unconnected 
either  with  bone  or  periosteum.  These  small  dermoids  prob- 
ably arise  in  the  fissure  between  the  fronto-nasal  plate  and  the 
cutaneous  fold  from  which  the  eyelid  is  formed.     The  fissure 


SEQUESTRATION  DERMOIDS. 


295 


between  the  tAvo  parts  which  form  an  eyehd  sometimes 
persists.  To  this  defect  the  term  coloboma  of  the  eyehd  is 
apphed.     (See  Fig.  179.) 

Dermoids  in  the  lower  section  of  the  orbito-nasal  fissure 
are  very  rare.  When  present  they  occupy  the  naso-facial 
sulcus,  as  in  Fig.  138. 

Nasal  Dermoids. — It  is  necessary  to  point  out  that  all 
dermoids  arising  in  connection  with  the  nose  are  not  associated 


Fig.  137. — Dermoid  at  the  inner  angle  of  the  orbit. 


with  the  orbito-nasal  fissure.  For  instance,  in  the  case  of  the 
child  in  Fig.  139,  there  is  a  small  dermoid  exactly  in  the 
middle  line  at  the  root  of  the  nose.  This  part  of  the  face  is 
not  traversed  by  a  fissure  in  the  embryo.  Nasal  dermoids, 
unassociated  with  the  orbito-nasal  fissure,  appear  either  as 
complete  cysts,  or  as  small  congenital  sinuses  in  the  skin  of 
the  nose.  Sometimes  such  sinuses  are  merely  shallow  recesses 
in  the  skin ;  in  other  cases  tufts  of  hair  project  from  their  orifices. 

The  mode  by  which  such  dermoids  arise  is  in  all  respects 
identical  with  that  which  gives  rise  to  dermoids  on  the  scalp. 

In  the  skull  of  the  early  embryo,  the  naso-frontal  plate, 
which  ultimately  forms  the  nose,  consists  of  a  lamina  of  hyaline 


296 


DEEMOIDH. 


cartilage  covered  externally  Ijy  skin  and  internally  Ijy  mucous 
membrane.  After  the  third  month  sections  made  through 
the  nasal  capsule,  immediately  anterior  to  the  ethmoid,  show 
that  the  skin  is  being  dissociated  from  the  underlying  cartilage 
by  bony  tissue,  which  eventually  becomes  the  nasal  bones. 


Fig.  13S.— Dermoid  arising  in  iiaso-facial  sulcus.     (After  Bramann.*) 

Ultimately  the  cartilage  disappears  as  a  result  of  the  pressure 
exercised  by  these  bones.  It  is  reasonable  to  believe  that  in  the 
gradual  separation  of  the  skin  from  the  cartilage  of  the  fronto- 
nasal plate  by  the  intrusion  of  the  nasal  bones,  small  portions 
of  skin  or  epithelium  become  sequestrated  and  eventually 
develop  into  dermoids.  This  explanation  is  more  fully  set 
forth  in  the  chapter  on  dermoids  of  the  scalp  and  dura  mater. 
It  is  necessary  to  mention  that  dermoids  at  the  root  of  the 

*  Langenbeck's  "  Archiv,"  bd.  xl.,  ]01. 


8EQ  UE8  TBA  TION  DERMOIDS. 


297 


nose  often  have  such  extremely  thin  walls  as  to  be  trans- 
lucent like  a  hydrocele  of  the  tunica  vaginalis  testis.  Such 
dermoids  contain  a  fluid  like  oil. 

Palatine  Dermoids. — In  the  early  embryo  the  nasal  and 
buccal   cavities   form    a   common   chamber.      Gradually   the 


Fig.  139. — Nasal  dermoid  in  a  child. 


palatine  processes  of  the  inaxillse  and  palate  bones  converge 
to  the  middle  line  and  form  the  hard  palate.  For  a  period, 
however,  the  palate  is  traversed  by  a  fissure,  which  eventually 
closes  from  before  backward.  Occasionally  this  union  never 
takes  place,  and  the  deformity,  cleft  palate,  is  the  result.  Small 
bodies  known  as  "  epithelial  pearls  "  are  sometimes  met  with 
in  the  middle  line  of  the  palate ;  they  are  not  uncommon  in 
the  mouths  of  children  at  birth,  hanging  by  short,  thin 
pedicles.  They  are  composed  of  concentric  masses  of  epi- 
thelial cells.*  The  mode  by  which  these  pearls  arise  is 
discussed  in  chapter  xxxviii. 

*  Leboucq,  "Arch,  de  Biologie,"  vol.  ii.  400. 


298 


DERMOIDS. 


Dermoids  sometimes  arise  in  the  palate ;  they  take  the 
form  of  tmnours,  inasmuch  as  the  skin  covers  the  outside  of 
the  mass  instead  of  hning  a  cavity ;  the  tumour  is  usually 
composed  of  connective  tissue  containing  striped  muscle  tissue 
and  cartilage.  The  dermoid  may  project  either  from  the 
buccal  or  pharyngeal  aspect  of  the  soft  palate.  It  is  occasion- 
ally difficult  to  determine  when  the  tumour  projects  into  the 
pharynx,  whether  it  grows  from  the  soft  palate  or  roof  of  the 
pharynx.*     Lamblf  reported  a   case  in  Avhich  a  pharyngeal 

dermoid  in  a  child  became  detached 
and  was  swallowed.  I^ext  day  it 
Avas  voided  by  the  anus. 

Adenomata  of  the  Palate. — A 
somewhat  rare  species  of  tumour  is 
occasionally  met  with  in  the  palate 
which  may  provisionally  form  an 
appendix  to  palatine  dermoids.  The 
tumours  in  question  are  often  referred 
to  under  the  name  of  palatine  adeno- 
mata. They  are  usually  oval  in  shape, 
and  vary  in  size  from  a  cob-nut  to  a 
hen's  e^g ;  the  latter  size  is  excep- 
tional. The  tumours  are  more  fre- 
quent in  the  soft  (Fig.  140)  than 
the  hard  palate,  and  as  a  rule  are 
distinctly  encapsuled ;  even  when  pendulous  the  tumour  has 
a  capsule.  In  structure  palatine  adenomata  are  very  complex  ; 
some  possess  glandular  tissue  with  ill-formed  ducts  and  acini, 
and  in  their  histological  features  mimic  cancer,  whilst  the 
stroma  in  which  these  gland-like  bodies  are  embedded  imitates 
sarcomatous  tissue.  Epithelial  pearls  are  often  abundant  and 
may  contain  horn.  Myxomatous  tissue  is  sometimes  present, 
and  Hutchinson  j  has  published  the  details  of  a  palatine 
adenoma  which  contained  lymphoid  follicles.  Palatine 
adenomata  occur  at  puberty  or  between  the  thirtieth  and 
fiftieth  years. §     They  are  innocent  tumours. 


.  140. — Pedunculated,  dermoid 
tumour  from  the  ])haryngeal 
aspect  of  the  soft  palate. 
{Arnold.) 


*  Hale  White,  Trans.  Path.  Soc,  vol.  xxxii.  201. 

t  Virchow's  "Archiv,"  bd.  cxi.  176. 

;J:  Trans.  Path.  Soc,  vol.  xxxvii.  490. 

§  Stephen  Paget,  Trans.  Path.  Soc.,  vol.  xxxviii.  348. 


299 


CHAPTER    XXXI. 

SEQUESTRATIOX    DERMOIDS    (conduded). 

Dermoids  of  the  Scalp  and  Dura  Mater. — The  common 
situations  for  dermoids  of  the  scalp  are  over  the  anterior 
fontanelle  and  occipital  protuberance.  In  these  situations 
they  may  be  confounded  with  sebaceous  cysts  or  with  menin- 
goceles.   Dermoids  of  the  scalp  often  have  a  thin  jDcdunculated 


Fig.  141. 


-Dermoid  of  tlie  scalp  connected  by  a  pedicle  with  the  dura  mater. 
(^Museum,  Middlesex  Hospital.) 


attachment  to  the  dura  mater,  the  pedicle  traverses  a  hole  in 
the  underlying  bone,  unless  the  cyst  is  over  a  fontaneUe. 

The  specimen  represented  in  Fig.  141  was  long  preserved 
in  the  museum  as  an  example  of  a  sebaceous  cyst  or  wen ;  its 
connection  with  the  dura  mater  induced  ]ne  to  examine  it,  and 
I  ascertained  that  the  cyst  contained  skin  and  hair.  The  term 
"  wen  "  used  to  be  applied  indifferently  to  sebaceous  cysts  and 
dermoids  of  the  scalp.  Sir  Astley  Cooper,*  in  his  well-known 
essay  on  "  Encysted  Tumours,"  even  included  orbital  dermoids 
among  wens.  In  describing  them,  he  writes : — "  The  largest 
size  I  have  known  them  acquire  has  been  that  of  a  common- 
sized  cocoa-nut,  and  this  grew  upon  the  head  of  a  man  named 

*  "  Surgical  Essays,"  vol.  ii.,  p.  213,  1818. 


300 


DERMOITJ,S. 


Lake,  who  kept  the  house  called  the  '  >Six  Bells '  at  Dartford. 
It  sprang  from  the  vertex,  and  gave  him  a  most  grotesque 
appearance,  for  when  his  hat  was  put  on  it  was  placed  upon 
the  tumour  and  scarcely  reached  his  head.     The  cyst  is  in  the 


Fig.  142. — Head  of  the  man  Lake  with  a  large  dermoid.     {From  a  cast  in  the  Mitseum, 
St.  Thomas's  Hospital.) 


collection  at  St.  Thomas's  Hospital,  also  an  excellent  cast  of 
his  head  taken  just  prior  to  the  operation." 

A  drawing  of  the  cast  is  given  in  Fig.  142.  I  have 
examined  the  cyst  in  the  museum  and  find  that  it  is  a  typical 
dermoid.  This  is  far  the  largest  dermoid  of  the  scalp  with 
which  I  am  acquainted.  The  cyst  contained  a  number  of 
round  balls,  some  having  a  diameter  of  1  cm.  These  con- 
sisted of  epithelial  cells  mixed  with  fat.  Some  of  the  balls 
have  been  preserved. 

Sibthorpe*  described  a  specimen  which  he  removed  from 

*  £rit.  Med.  Journal,  1888,  vol.  i.,  p.  350. 


SEQUESTRATION  DERMOIDS.  301 

the  scalp  of  a  young  Hindu.  The  tumour  had  been  present 
since  birth.  When  excised  it  was  of  the  shape  and  size  of  a 
cocoa-nut.     It  contained  short  hairs,  grease,  and  fat  cells. 

When  dermoids  are  situated  over  the  anterior  fontanelle 
they  may  easily  be  mistaken  for  meningoceles. 

Arnott*  published  the  details  of  an  instructive  case  of 
dermoid  situated  over  the  anterior  fontanelle  in  an  infant  a 
few  days  old.  The  tumour  exactly  resembled  a  meningocele, 
"  rising  and  fallmg  with  regular  pulsation,  and  swelling  when 
the  child  coughed "  ;  the  resemblance  was  so  strong  that  it 


Fig.  143. — Congenital  tumour  over  the  anterior  fontanelle.     {After  HutcMnaon.) 

was  regarded  as  a  meningocele.  A  few  weeks  later  the  child 
died  from  broncho-pneumonia,  and  the  cyst  was  found  to  be 
a  dermoid.  The  specimen  is  preserved  in  the  museum  of 
St.  Thomas's  Hospital. 

Giraldesj-  records  a  case  even  more  remarkable  than  this 
A  child,  three  months  old,  had  an  ovoid  tumour,  of  the  size  of 
a  pigeon's  egg,  over  the  anterior  fontanelle.  The  tumour  was 
covered  with  fine  white  hair,  and  did  not  pulsate  with  respira- 
tion. It  was  thought  to  be  a  meningocele,  and  in  order  to 
establish  a  diagnosis  it  was  punctured  with  a  fine  trocar,  and 
fluid  resembling  that  found  in  meningoceles  was  withdrawn. 
Notwithstanding  numerous  subsequent  punctures,  the  tumour 
maintained  its  original  volume.  Some  months  later  it  was 
removed,  Giraldes  being  still  under  the  impression  that  it  was 
a  meningocele ;  but  it  was  found  to  be  a  typical  dermoid. 

*  Trans.  Path.  Soc,  vol.  xxv.,  p.  228. 
t  "  Maladies  Chir.  des  Enfants,"  p.  342. 


302  DERMOIDS. 

The  clinical  characters  of  such  tumours  occurring  at  the 
anterior  fontanelle  may  be  illustrated  by  the  case  reported  by 
Hutchinson  (Fig.  143).*  As  the  tumour  distinctly  filled  when 
the  child  cried,  it  was  not  interfered  with.  At  the  date  when 
the  case  was  published  the  patient  was  a  fine  young  man  of 
eighteen,  and  the  cyst  had  not  shown  any  tendency  to  increase 
since  birth. 

Dermoids  in  the  neighbourhood  of  the  occipital  protuber- 
ance may  lie  on  the  inner  aspect  of  the  occipital  bone  and 
are  nearly  always  in  relation  with  the  tentorium  cerebelli. 
Examples  have  been  described  by  Turner,t  Ogle, J  Pearson 
Irvine,§  and  Lannelongue.||  They  occurred  in  children, 
and  in  Ogle's  case  there  was  defective  development  of  the 
squamous  portion  of  the  occipital  bone.  In  Lannelongue's 
patient,  a  girl  seven  3"ears  old,  the  dermoid  had  attained  the 
size  of  an  orange ;  it  produced  marked  symptoms,  such  as 
paralysis,  amaurosis  and  coma,  ending  in  death. 

Although  at  first  sight  a  dermoid  connected  with  the 
dura  mater  and  projecting  into  the  brain  seems  to  violate  all 
embryological  rules,  nevertheless,  when  we  view  this  membrane 
from  a  morphological  standpoint,  the  strangeness  vanishes 
and  a  satisfactory  explanation  is  forthcoming. 

Morphologically  considered,  the  bony  framework  of  the 
skull  is  an  additional  element  to  the  primitive  cranium  which 
is  represented  by  the  dura  mater,  and  as  I  have  elsewhere  ^ 
endeavoured  to  show,  the  term  extracranial  should  strictly 
apply  to  all  tissues  outside  the  dura  mater.  In  surgical 
practice  we  find  it  convenient  to  regard  the  bones  as  the 
boundary  of  the  skull,  but  morphologically  this  is  inaccurate ; 
the  skull-bones  must  be  regarded  as  secondar}^  cranial  ele- 
ments. Early  in  embryonic  life  the  dura  mater  and  skin  are 
in  contact ;  gradually  the  base  and  portions  of  the  side-walls 
of  the  membranous  cranium  chondrify,  thus  separating  the 
skin  from  the  dura  mater.     In  the  vault  of  the  skull,  bone 

*  "  Illustrations  of  Clinical  Surgery,"  vol.  ii.,  plate  xlvi. 
t  St.  Earth.  Hosp.  Eep.,  vol.  ii.  62. 
+  Brit,  and  For.  Mecl.-Chir.  Review,  1865. 
§  Trans.  Path.  Soc. ,  vol.  xxx.  195. 
II  "Affections  Congenitales,"  1891,  p.  49. 

H  Journal  of  Anat.  and  Physiology,  vol.  xxii.,  p.  28  :  "  A  Critical  Study  in 
Cranial  Morphology." 


SEQUESTRATION^  DERMOIDS.  303 

develops  between  tlie  dura  mater  and  its  cutaneous  cap,  but 
the  skin  and  dura  mater  remain  in  contact  alono-  the  various 
sutures  even  for  a  year  or  more  after  birth.  This  relation  of 
the  dura  mater  and  skin  persists  longest  in  the  region  of  the 
anterior  fontanelle  and  the  neighbourhood  of  the  torcular. 
Should  the  skin  be  imperfectly  separated,  or  a  portion  remain 
persistently  adherent  to  the  dura  mater,  it  would  act  precisely 
as  a  tumour  germ  and  give  rise  to  a  dermoid  cyst.  Such  a 
tumour  may  retain  its  original  attachment  to  the  dura  mater, 
and  its  pedicle  become  surrounded  by  bone :  the  dermoid 
would  lie  outside  the  bone,  but  be  lodged  in  a  depression  on 
its  surface,  with  an  aperture  transmitting  its  pedicle.  On  the 
other  hand,  the  tumour  may  become  separated  from  the  skin 
by  bone ;  it  would  then  project  on  the  inner  surface,  or 
between  the  layers  of  the  dura  mater.  If  this  view  of  the 
origin  of  dermoids  of  the  scalp  be  admitted,  we  must  then 
slightly  modify  our  teaching,  and  say  that  the  depressions 
in  which  dermoids  of  the  cranium  are  lodged  arise  as 
imperfections  in  the  developmental  process,  and  are  not  due 
to  absor^Dtion  induced  by  the  pressure  they  exert ;  further, 
the  fibrous  connection  of  such  dermoids  with  the  underlying- 
dura  mater  is  primary,  not  accidental. 

The  relation  of  dermoids  to  the  tentorium  requires  further 
consideration.  A  study  of  the  development  of  the  tentorium 
cerebelli  will  demonstrate  that  it  is  composed  of '  tAvo  folds  of 
dura  mater,  and  it  arises  as  an  infolding  or  crease  in  this 
membrane,  caused  by  the  rapid  backward  extension  of  the 
developing  cerebrum.  The  opposed  surfaces  of  the  tentorial 
lamellse,  like  the  outer  surface  of  the  dura  mater  in  relation 
with  the  cerebrum,  were  originahy  in  contact  with  the  skin, 
and  as  the  posterior  margins  of  the  bay  or  recess  formed  by 
the  crease  in  the  dura  mater  come  together,  a  portion  of  the 
skin  may  become  nipped  or  even  sequestrated  between  the 
layers  of  the  tentorium;  this  preserving  its  vitality,  and  in 
some  cases  its  cutaneous  connections,  may  ultimately  give  rise 
to  an  intracranial  dermoid. 


304 
CHAPTER    XXXII. 

IMPLANTATION     CYSTS. 

These  small  tumours  should  form  a  group  by  themselves  and 
not  be  included  among  dermoids ;  but  their  consideration  in 
connection  with  sequestration  dermoids  is  imperative,  as  they 
furnish  valuable  (almost  experimental)  evidence  of  the  reality 
of  the  theory  that  this  genus  of  dermoids  arises  from  "  rests/' 
the  results  of  faulty  coalescence.  Implantation  cysts  are  caused 
by  the  accidental  transplantation  of  portions  of  skin,  surface 
epithelium,  or  hair  bulbs  into  the  underlying  connective 
tissue.  The  transplanted  tissue  acts,  in  many  instances,  as  a 
graft  and  ultmiately  forms  a  small  tumour.  Cysts  of  this 
character  have  been  described  as  sebaceous 
cysts,  dermal  cysts  and  dermoids.  They  occur 
most  commonly  on  the  fingers,  and  especially 
on  the  fingers  of  women  who  live  by  sewing, 
shoe-makers,  carpenters,  and  the  like. 
'^tioncystfronuhe  PolaiUou*  has  Written  an  account  of  digital 

ipo  le  ng  .  (^[Qrmoids,  and  gives  M.  Muron  the  credit  of 
first  recognising  the  character  of  such  cysts  (1868).  He  says 
the  tumours  are  more  frequent  on  the  palmar  than  the  dorsal 
aspect  of  the  digits,  but  he  fails  to  associate  them  with  ante- 
cedent injury,  though  he  distinctly  points  out  that  they  occur 
mainly  on  the  hands  of  workpeople  and  soldiers.! 

A  digital  dermoid  in  the  subcutaneous  tissue  of  the  finger- 
tip is  represented  in  Fig.  144.  The  specimen  was  placed 
at  my  disposal  by  Mr.  Shattock,  who  described  its  micro- 
scopical characters  thus  :  "  It  appeared  as  if  a  piece  of  the 
skin  covering  the  pulp  of  ,the  finger  had  been  inverted."  There 
was  no  clear  history  of  old  mechanical  injury,  but  the  patient 
was  a  farrier. 

Implantation  cysts  occur  in  other  parts  of  the  body. 
Treves  J  described  a  case  which  occurred  in  a  woman  twenty- 

*  "  Die.  Ency.  des  Sci.  Med.,"  1884,  in  an  admirable  article,  "  Doigt." 
f  The  Trans.  Path.  Soc,  vol.  xxxA^  onwards,  contain  careful  descriptions  of 
several  cases  by  Barker,  Bowlby,  Poland,  and  others. 
X  Lmicet,  1889,  vol.  i.,  p.  682. 


IM PLANTATION  CYSTS.  305 

nine  years  of  age.  The  tumour  was  situated  over  the  external 
occipital  protuberance,  and  measured  7  cm.  in  its  long  axis. 
It  was  cystic,  the  walls  being  lined  internally  with  skin 
furnished  with  hair  5  to  8  cm.  long.  The  cavity  also  con- 
tained sebaceous  material  and  mucus.  The  patient  affirmed 
that  the  tumour  appeared  eight  years  previously  after  a 
laceration  of  the  scalp,  the  scar  of  which  was  visible  at  the 
time  the  tumour  was  removed ;  it  was  situated  some  httle 
way  from  the  cyst. 

These  cases  are  of  interest,  for  they  serve  to  throAv  light 
on  some  cysts,  containing  hair  and  wool,  preserved  in  the 
museum  of  the  Royal  College  of  Surgeons.  Two  of  the  cysts 
are  from  sheep,  and  contain  wool  embedded  in  fatty  matter. 
Unfortunately,  the  catalogue  affords  no  information  as  to 
the  region  of  the  body  whence  they  were  removed.  The 
third  and  fourth  specimens  were  removed  from  the  shoulder 
of  a  cow  that  had  six  legs.  The  cysts  contain  light  hair, 
fatty  and  calcareous  matter.  These  four  specimens  are 
Hunterian.  The  fifth  specimen  was  removed  from  beneath 
the  integuments  of  the  shoulder  of  an  ox.  It  contained 
slender  black  hairs,  resembling  those  on  the  skin  of  the  animal, 
mixed  with  fat.  I  once  obtained  a  good  example  of  an 
implantation  cyst  from  the  axilla  of  an  ox.  The  cyst  was  as 
large  as  a  billiard  ball,  and  in  structure  resembled  a  piece  of 
inverted  skin.  Fortunately,  these  cysts  can  be  explained  on 
the  same  lines  as  dermoid  cysts  of  the  fingers  in  man.  The 
sticks  used  by  cattle-drovers  are  armed  at  the  end  with  a 
sharp  iron  spike,  2-5  cm.  (1")  long,  with  which  they  "  prod  "  the 
beasts,  often  very  severely.  It  may  be  assumed  that  punctures 
produced  with  such  an  instrument  may  lead  to  the  deposition 
of  dermal  grafts  beneath  the  skin,  which  may  give  rise  to 
dermoids  in  the  same  way  as  punctured  wounds  in  the  skin 
of  men  and  women.  Punctured  wounds  in  sheep  and  oxen 
may  also  be  caused  by  projecting  nails,  iron  spikes,  tenter- 
hooks, and  the  like. 

The  opinion  that  dermoids  may  arise  in  the  subcutaneous 
tissues  by  implantation,  receives  the  strongest  possible  con- 
firmation from  what  we  know  of  similar  cysts  of  the  iris  and 
cornea  associated  with  mechanical  injur}^ 

Iritic  Cysts. — Cysts  of  the  iris  are  of  comparative  rarity, 


306  DERMOIDS. 

generally  appearing  as  transparent  vesicles  situated  on  its 
anterior  surface.  As  a  rule,  they  are  sessile,  but  occasionally 
possess  a  pedicle.  The  contents  may  be  opaque,  but  in 
exceptional  cases  they  have  been  filled  with  sebaceous  material, 
such  as  fills  the  cavities  of  dermoids. 

Mr.  Hulke*  has  collected  some  valuable  facts  in  relation 
to  such  cysts,  and  states  that  in  fifteen  out  of  nineteen  cases, 
as  well  as  in  two  reported  by  himself,  there  was  distinct 
history  of  antecedent  mechanical  injury.  He  suggested  that 
some  of  these  cysts  originated  from  portions  of  Descemet's 
membrane,  which  may  have  been  torn  from  the  cornea  and 
implanted  on  the  iris.     Mr.  Power  mentioned  to  me  the  case 


Fig.  145. — Large  implantation  cyst  of  the  cornea,  following  an  injury.     (After  T.  Collins.) 


of  a  sailor  who  wounded  his  cornea  with  a  knife ;  afterwards 
a  small  cyst  was  found  on  the  iris,  with  an  eyelash  sprouting 
from  its  middle.  On  this  head  we  have  the  accumulated  experi- 
mental observations  of  Dooremaal,  Goldzieher,  Schweninger, 
Zahn,  and  Masse,  who  introduced  various  kinds  of  tissue,  such 
as  cartilage,  hairs,  and  conjunctiva,  into  the  anterior  chambers 
of  rabbits'  eyes.  In  some  instances  the  transplanted  tissues 
grew;  in  others  they  were  absorbed  or  extruded  from  the  globe. 
Corneal  Cysts. — In  addition  to  the  evidence  furnished  by 
implantation  cysts  of  the  iris  we  know  that  similar  cysts  occur 
in  the  cornea.  Treacher  Collins  has  investigated  this  matter, 
and  has  published  some  valuable  researches  in  which  he  has 
succeeded  in  demonstrating  that  after  gunshot  injuries  of  the 
eyeball,  blows  from  tip-cats,  and  incisions  made  for  the 
extraction  of  cataracts,  cysts,  usually  of  small  size,  are  liable 

*  "  On  Cases  of  Cysts  of  the  Iris,"  E.  Lond.  Ophth.  Hosp.  Eep.,  vol.  vi., 
1869';  also  Hosch,  "Ex.  Studien  iiber  Iriscysten,"  Yirchow's  "  Archiv,"  bd. 
xcix.,  s.  449. 


IMPLANTATION  GY8T8. 


307 


to  form  in  the  cornea  near  the  seat  of  injury.  In  some  of 
the  specimens,  as  for  instance  the  eye  sketched  in  Fig.  145, 
the  cyst  may  be  very  large  and  conspicuous  ;  when  examined 
microscopically,  their  inner  walls  are  found  lined  with  layers 
of  cells  identical  with  those  covering  the  anterior  surface 
of   the    conjunctiva.      (Fig.    146.)      The  structure   of   these 


Fig.  146. — Section  of  the  cyst  in  the  preceding  figure,  highly  magnifled. 
the  laminated  epithelium.     (After  Treacher  Collins.) 


It  shows 


cysts,  taken  in  conjunction  Avith  the  antecedent  injuries, 
thoroughly  supports  the  view  that  they  arise  from  conjunctival 
epithelium  transplanted  into  the  deep  tissues  of  the  cornea. 
The  most  careful  investigation  into  the  origin  and  structure 
of  corneal  cysts  has  been  undertaken  by  Treacher  Collins,* 
whose  communications  deserve  the  most  attentive  study  from 
all  interested  in  this  subject. 

*  Royal  London  Ophth.  Hosp.  Reports,  vol.  xii. 


308 


CHAPTER    XXXIII. 

TUBULO-DERMOIDS. 


There  exist  in  the  human  embryo  certain  canals  and 
passages,  many  of  which  normally  disappear  before  birth. 
Among  these  obsolete  canals  there  are  three  that  require 
especial  consideration  in  connection  with  dermoids — viz.,  the 
thyro-lingual  duct,  the  post-anal  gut,  and  the  branchial  clefts. 
The  remainder  will  be  considered  in  connection  with  cysts. 

The  Thyro-glossal  Duct. — The  thyroid  gland  of  man 
consists  of  two  lobes  united  by  a  narrower  portion  or  isthmus. 
His  maintains  that  the  three  parts  of  this  gland  arise  separately. 
The  lateral  lobes  originate  independently  of  the  isthmus  ;  the 
latter  is  derived  from  a  mediau  tubular  outgrowth  from  the 
ventral  wall  of  the  embryonic  pharynx  known  as  the  th3T.^o- 
glossal  duct.  This  duct  bifurcates  at  its  lower  end  and  gives 
rise  to  the  thyroid  isthmus,  which  fuses  with  the  lateral 
thyroid  rudiments,  and  assists  in  forming  the  lobes  of  the 
gland.  Originally  the  duct  extends  as  far  upwards  (forwards 
in  the  embryo)  as  the  dorsum  of  the  tongue,  but  as  the  body 
of  the  hyoid  bone  develops,  the  duct  becomes  divided  into 
an  upper  segment,  the  lingual  duct,  and  a  lower  portion,  the 
thyroid  duct.  In  the  ordinary  course  of  development  these 
ducts  disappear,  but  in  some  cases  they  persist  and  attain 
a  fair  size,  and  in  others  give  rise  to  pathological  conditions 
of  great  interest. 

There  are  at  least  three  abnormalities  which  appear  to  be 
associated  with  vagaries  of  the  thyro-glossal  duct,  viz.  (1) 
lingual  dermoids,  (2)  median  cervical  fistulse,  (3)  accessory 
thyroids.  It  will  be  convenient  to  begin  with  dermoids  in  the 
tongue. 

Lingual  Dermoids  have  been  frequently  mistaken  for 
sebaceous  cysts,  and  until  recently  were  regarded  by  most 
surgical  writers  as  rarities.  Since  Barker*  published  his 
excellent  paper  on  the  subject,  many  cases  have  been  observed 
and  recorded.    Barker  analysed  sixteen  cases,  and  showed  that 

*  Trans.  Clin.  Soc,  vol.  xvi. ,  p.  215. 


TUBULO-BEBMOIDS.  309 

they  may  be  situated  between  the  genio-hyo-giossus  and 
mylo-hyoid  muscles,  or  occupy  a  central  position  between  the 
genio-hj^o-glossi  muscles. 

The  lateral  group  is  discussed  in  the  section  devoted  to 
dermoids  arising  in  branchial  clefts ;  those  occupying  the 
centre  of  the  tongue  concern  us  now. 

Central  dermoids  of  the  tongue  are  rarely  sufficiently  large 
to  attract  attention  in  infants.  Richet,  however,  removed 
one  from  a  child,  a  few  days  old,  in  I'Hopital  St.  Louis. 
Most  of  the  cases  have  occurred  in  young  adults,  and  in 
many  mstances  have  been  regarded  as  ranul?e.  As  a  rule, 
they  cause  the  floor  of  the  mouth  to  bulge  on  each  side  of  the 
frsenum,  and  when  unusually  large,  a  prominence  is  noticed 
under  the  chin.  In  at  least  two  cases  the  swelling  has  been 
mistaken  for  an  abscess.  The  dermoid  can  be  removed,  when 
small,  through  the  floor  of  the  mouth,  and  when  large  by 
dissection  through  a  median  incision  extending  from  the  chin 
to  the  body  of  the  hyoid.  The  cyst-wall  must  be  completely 
dissected  out.  A  man,  aged  twenty-four  years,  came  under 
my  care  with  a  lingual  dermoid  that  had  been  previously 
mistaken  for  a  ranula  ;  during  nine  years  he  had  been 
submitted  to  seven  operations  without  success.  On  dissecting 
out  the  cyst  I  found  it  firmly  adherent  to  the  body  of  the 
hyoid  bone,  and  extending  between  the  genio-hyo-glossi  to 
the  foramen  caecum. 

The  walls  of  lingual  dermoids  are  composed  of  fibrous 
tissue,  lined  internally  with  squamous  epithelium  beset  with 
hair,  and  sometimes  glands.  In  one  case  reported  by  Stephen 
Paget*  there  was  a  deposit  of  pigment  in  the  cyst- wall.  The 
contents  of  these  cysts  are  epithelial  cells,  hair,  sebum,  and 
cholesterine.  Should  the  cyst  burst,  then  it  would  suppurate 
and  become  very  disagreeable. 

Dermoids  lying  in  the  middle  line  of  the  tongue  arise 
in  the  lingual  duct.  This,  when  fully  developed,  extends 
from  the  foramen  caecum  to  the  posterior  surface  of  the  body 
of  the  hyoid :  the  foramen  caecum  marks  the  termination 
of  this  duct  on  the  dorsum  of  the  tongue ;  occasionally  it 
is  so   large   that   a   narrow  probe   may  be   passed   along   it. 

*  Trans.  Path.  Soc,  vol.  xxxvii.,  p.  225. 


310 


DEBMOIUS. 


The  duct  lies  exactly  between  the  genio-hyo-glo.ssi  iiiuscles, 
and  is  not  infrequently  replaced  by  a  solid  fibrous  cord.  It  is 
easy  to  understand  that  if  a  persistent  duct  should  have  its 
upper  end  obstructed  or  obliterated,  the  continual  shedding 
of  the  epithelium  which  lines   it   and  the  accumulation  of 


Fig.  147. — Large  lingual  dermoid,  i)rotrudiug  from  tlie  moutli.    (Gray.) 

sebum  from  the  glands  would  convert  it  into  a  cyst,  which  m 
due  course  would  assume  such  a  size  as  to  come  within  the 
range  of  clinical  observation.  Such  a  tumour  would  project 
into  the  floor  of  the  mouth  and,  when  unusually  large,  form  a 
swelling  above  the  body  of  the  hyoid  bone.  In  some  rare 
instances  they  project  from  the  mouth,  as  in  the  negro  whose 
case  was  reported  by  Barker.*  This  man  was  under  the  care 
of  Dr.  Wellington  Gray,  in  Bombay.     (Fig.  147.) 

The  tumour  protruded  from  the  man's  mouth,  and  was  as 
large  as  a  medium-sized  cocoa-nut.  It  completely  filled  the 
space  between  the  jaws,  the  upper  incisor  teeth  projected 
horizontally  forwards,  whilst  those  of  the  lower  jaw  were  not 
only  loosened,  but  their  direction  was  reversed.     The  tumour 

*  Trans.  Clin.  Soc,  vol.  xxiv.,  p.  68. 


TUBULO-DEBMOIDS.  311 

caused  a  swelling  in  the  neck  as  low  as  tlie  thyroid  cartilage. 
The  patient's  voice  was  an  indistinct  mumble,  and  only 
fluid  food  could  be  taken.  The  tumour  was  successfully 
removed :  it  contained  forty  ounces  of  pultaceous  matter, 
consistmg  of  epithelium,  fat,  and  cholesterine.  The  walls 
were  lined  with  epithelium.  Such  large  cysts  are  excessively 
rare.  Stephen  Paget*  described  a  very  large  cyst  which  he 
successfully  removed  from  a  child  four  years  old,  in  whom  it 
was  congenital.  Its  anatomical  relations  were  like  those  of  a 
dermoid  arising  in  the  lingual  duct.  It  contained  fluid  of  a 
yellow  colour,  and  was  so  large  as  to  project  from  the  child's 
mouth  and  almost  touch  the  sternum. 

In  addition  to  the  common  variety  of  dermoid,  the  tongue 
is  occasionally  occupied  by  tumours  Avhich  in  structure  re- 
semble the  thyroid  gland.  They  occur  in  the  neighbour- 
hood of  the  foramen  caecum,  between  the  genio-hyo-glossi 
muscles.  Bernays  has  given  a  careful  description  of  such  a 
tumour,  which  he  removed  from  the  tongue  of  a  girl  seven- 
teen years  of  age.  In  the  account  of  the  case  Bernaysf  clearly 
associates  the  tumour  with  the  lingual  duct. 

Butlin  X  has  recorded  two  cases  that  came  under  his 
notice :  one  in  a  female  thirty-two  years  of  age,  and  the 
other — also  a  female — twenty-seven  3^ears  old.  The  tumours 
were  situated  at  the  base  of  the  tongue,  where  they  formed 
prominent  swellings  just  in  front  of  the  epiglottis,  and  caused 
very  little  inconvenience. 

A  curious  effect  of  the  partial  removal  of  these  tumours  is 
noted  by  Butlin.  The  interference  excited  growth  and  for  a 
time  caused  the  remnants  to  increase  in  size  ;  gradually  growth 
ceased,  the  tumour  remained  passive,  and  then  dwindled  to 
half  its  bulk.  This  happened  in  the  two  cases  under  Butlin's 
care  and  in  a  case  recorded  by  Rushton  Parker. 

Wolf  §  has  described  an  example  which  occurred  in  a  girl  of 
eighteen  years.  He  removed  the  tumour  from  the  substance 
of  the  base  of  the  tongue.     As  its  microscopical  characters 

*  Trans.  Path.  Soc,  vol.  xliii.  57. 
f  St.  Louis  Medical  and  Surgical  Joimial,  \ol.  Iv.  201. 
%  Trans.  Clin.  Soc,  vol.  xxiii.  118. 

§  Langenbeck's  "  Archiv,"  bd.    xxxix.  224.     See  also  Warren,  International 
Journal  of  Med.  Science,  October,  1892,  vol.  civ.  p.  377. 


312  DERMOIDS. 

SO  strongly  resembled  thyroid  gland,  Wolf  regarded  it  as  an 
accessory  thyroid  body  (accessorisJte  scJdlddrv.se). 

We  have  now  to  deal  with  abnormalities  arising  in  con- 
nection with  the  thyroid  section  of  the  thyro-lingual  duct. 
It  will  be  convenient  to  begin  with  the  consideration  of  median 
cervical  fistulse.  These  openings  occur  singly,  and  open  at  some 
point  in  the  middle  line  of  the  neck  between  the  hyoid  bone 
and  the  top  of  the  sternum.  The  common  situation  is  a  little 
below  the  level  of  the  cricoid  cartilage.  Median  cervical 
listulse  differ  from  those  arising  in  connection  with  branchial 
clefts  in  the  fact  that  they  are  never  congenital ;  they  may 
occur  soon  after  birth  or  make  their  appearance  as  late  as  the 
fourteenth  year. 

Raymond  Johnson*  has  clearly  pointed  out  that  median 
cervical  fistulse  are  often  preceded  by  a  swelling  in  the  middle 
line  of  the  neck  which  either  ruptures  or  is  opened  by  the 
surgeon ;  this  leaves  a  sinus  which  never  closes.  Johnson 
illustrates  these  facts  by  careful  descriptions  of  three  cases 
that  he  observed. 

In  some  cases  an  oval  swelling  the  size  of  an  almond  forms 
in  the  middle  line  of  the  neck,  at  the  level  of  the  thj^roid 
isthmus ;  from  this  a  rounded  cord  may  sometimes  be  felt 
passing  upwards  to  the  hyoid  bone. 

The  fistulte  easily  admit  an  ordinary  probe,  which  always 
passes  upwards  to  the  body  of  the  hyoid.  Hence  when  the 
surgeon  attempts  to  dissect  out  these  sinuses  he  finds  that 
they  run  upwards  between  the  sterno-hyoid  muscles  and 
beneath  the  deep  fascia  of  the  neck  to  reach  the  hyoid  bone. 
Few  of  these  fistulee  have  been  examined  microscopically,  but 
in  one  of  Johnson's  cases  the  cord  dissected  out  was  4  cm.  in 
length,  equal  in  calibre  to  a  No.  6  English  catheter,  and  com- 
posed of  concentric  layers  of  fibrous  tissues.  The  inner  surface 
was  covered  with  stratified  epithelium.  Unless  the  whole 
length  of  the  duct  is  extirpated,  the  sinus  will  persist. 

The  fact  that  these  median  cervical  fistulse  are  preceded  by 
a  swelling  is  a  fact  of  great  interest.  Cussetf  described  the 
case  of  a  little  girl  five  years  old,  in  the  middle  line  of  whose 
neck  there  was  a  swelling  below  the  hyoid  bone ;  this  opened 

*  Trans.  Path.  Soc,  vol.  xli.  325. 

t  "  Kystes  et  Fistules  d'origine  branchiale."     Paris,  1877. 


TUBULO-DERMOIDS.  313 

and  discharged  a  glairy  fluid  and  left  a  sinus  that  j)''issed 
upwards  to  the  base  of  the  tongue ;  but  Johnson  seems  to  be 
the  first  to  emphasise  the  fact  that  a  swelling  in  the  neck 
precedes  the  sinus. 

Our  knowledge  of  the  nature  of  these  fistulse  was  not  very 
satisfactory  until  the  publication  of  an  able  paper  by  Dr.  C.  F. 
Marshall,*  detailing  an  account  of  the  anatomy  of  the  parts  in 
the  neighbourhood  of  the  hyoid  bone  of  a  child  five  years  old, 
who  had  a  median  sinus  in  the  neck. 

The  patient  was  admitted  into  a  hospital  for  the  purpose 
of  having  the  duct  excised ;  it  contracted  diphtheria  and 
died  before  the  operation  could  be  performed. 

In  the  median  line  of  the  neck,  2'5  cm.  (1")  above  the 
sternum,  there  was  a  sinus  which,  during  life,  discharged  a 
small  quantity  of  mucous  fluid.  From  this  opening  a  hard  cord 
could  be  felt  extending  up  to  the  hyoid  bone.  On  dissecting 
the  front  of  the  neck  this  cord  was  found  to  be  tubular  and 
patent  up  to  within  1  cm.  of  its  termination :  the  upper  end 
was  firmly  attached  to  the  hyoid  bone,  the  lower  end  dilated 
into  a  thin-walled  sac  opening  on  to  the  surface  of  the  skin. 
The  sac  and  tube  lay  between  the  skin  and  the  anterior 
layer  of  the  deep  cervical  fascia :  at  no  place  was  there  any 
connection  with  the  thyroid  gland. 

On  dividing  the  hyoid  bone  the  tube  could  be  traced  as  an 
ill-defined  fibrous  cord  on  to  its  dorsal  surface,  to  which  it 
was  closely  attached,  and  through  the  substance  of  the  tongue 
to  the  foramen  caecum.  About  2  cm.  from  the  foramen  it 
again  became  patent,  and  continued  so  up  to  the  surface  of 
the  tongue.  The  canal  was  thus  open  at  both  ends,  but 
impervious  in  the  middle. 

On  further  dissection  a  lobus  pyramidalis  was  found  con- 
nected with  the  left  side  of  the  thj^roid  isthmus,  its  upper  end 
being  united  to  the  median  fibrous  cord  at  the  same  place 
as  the  above-mentioned  canal.  In  other  words,  the  fibrous 
cord  behind  the  hyoid  bone  was  continuous  both  with  the 
pyramidal  lobe  of  the  thyroid  and  Avith  the  tube  leading  to 
the  superficial  sinus. 

The  relations  of  the  parts  are  admirably  shown  in  Fig.  148, 
which  indicate  exceedingly  well  the  probable  mode  by  which 

*  Journal  of  Anat.  and  Phys.,  vol.  xxvi.,  p.  94. 


3U  DERMOIDS. 

these  median  fistulse  arise,  for  a  glance  at  the  diagram  is 
sufficient  to  suggest  that  they  are  in  the  first  place  retention 
cysts  formed  in  a  persistent  thyroid  duct,  and  the  pressure  of 
the  cyst  ultimately  causes  the  skin  to  yield  and  form  a  sinus. 

Marshall  is  of  opinion  that  the  canal  is  the  remnant  of 
one  of  the  bifurcations  of  the  original  median  thyroid  rudi- 
ment, the  remaining  bifurcation  forming  the  pyramidal  lobe 
_____^  of  the  thyroid  body.     At  pre- 


Sac. 


sent  there  is  little  to  support 
^       {  >  y''  - '     ^\        Kostanecki    and    Miel^.cki's* 

j  ^^  -  .:,       ;^-^       contention  that  median   cer- 

/  "'    ,^""^'^.B     vical  fistulae  arise  in  connec- 

V^---'--  ^  j£       7  tion    with    the    "  precervical 

"""**'*'*•*-  _  ;,r  Cl-.--',  ^'^'Z^.   sinus." 

Hyoidbont.      ':f _...■'- -"""/"''^^I        Accessory  Thy T olcls. — 
^  1^,  ,,-'—„;     /    The  consideration  of  accessory 

Thyroid  cartilage ||£.-         '^'^'      thyroids      naturally     follows 

Pyramid  of  the    ^■^''^\         ^-"^        ou  the  description  of  median 

thyroid  gland.   ;:;,\\_,/     '       ccrvical    tistulte,  for   there  is 

|:      '  '  good  reason   to   believe   that 

Thyroid  gland. |v  • . '-;;:  ^       the  thyroid  duct  is  the  source 

J  i       of  some  of  these  bodies.     The 

\_         /       existence  of  accessory  thyroids 

V      '- -i        has  lonar  been  known,t  and  in 

p,;"-:^       recent  years  they  have  been 

'7'"  carefully  studied.     It  will  be 

Trachea.  couvonient  to  cousicler  them 

according  to  their  situation : — 

B^c'to^ifailucf''^^'^  A,  foramen  c*cum ;  (^i^  Median  acccssory  thyroids ; 

(2)  lateral  accessory  thyroids. 
1.  Median  Accessory  Thyroids. — The  most  frequent 
situation  in  which  to  find  these  small  bodies  is  in  the 
neighbourhood  of  the  hyoid  bone,  and  Streckeisen,  who  has 
published  the  results  of  a  careful  inquiry  into  this  question, 
divides  them  into  four  groups : — (1)  Those  superficial  to 
the  mylohyoid  muscle— ^^re-Zi^/o-ic^.  (2)  Between  or  in  the 
substance  of  the  genio-hyoids — swpra-hyoid.     (3)  Above  the 

*  Virchow's  "  Archiv,"  bd.  cxx.  385  and  cxxi.  55. 

+  Albers'  "  Atlas  der  Path.  Anat.,"  Abth.  ii.,  Taf.  xxv.,  xxvi.,  and  xxxix.;  also 
Virchow,  "Die  Krankhaften  Geschwiilste,"  bd.  iii.  s.  13. 


.    148. — Diagram    to    show    the    relation   of 
parts  in  a  ease  of  median  cervical  fistula. 


TUBULO-BEBMOIDS.  315 

genio-liyoid — epi-lhyoid.  (4)  They  may  be  lodged  in  the 
hollow  or  even  in  the  substance  of  the  hyoid  bone — intra- 
hyoid.  Another  common  place  m  which  to  hnd  them  is  m 
the  hoUow  formed  by  the  two  lobes  of  the  thyroid. 

It  has  already  been  pointed  out  that  the  lingual  duct  is, 
in  the  early  embryo,  directly  continuous  with  the  thyroid 
duct,  and  that  the  continuity  of  the  two  is  interrupted  by  the 
development  of  the  body  of  the  hyoid.  It  was  also  stated 
that  the  terminal  portion  of  the  thyroid  duct  bifurcates  and 
gives  rise  to  the  isthmus  of  the  thyroid  and  adjacent  portion 
of  each  lateral  lobe. 

Usually  all  traces  of  the  duct  disappear,  but  in  a  fair 
portion  of  cases  it  forms  a  pyramidal  process  for  the  thj^roid, 
and  not  infrequently  it  persists  as  a  duct  running  fifom  the 
hyoid  bone  to  the  thjToid  isthmus,  and  contains  a  lumen 
capable  of  admitting  an  ordinary  probe ;  in  some  instances  it 
is  an  impervious  cord,  and  occasionally  it  is  moniliform. 

As  the  duct  is  directly  associated  with  the  formation  of 
the  thyroid  body,  and  as  median  accessory  thyroids  are  found 
directly  in  its  track  from  the  hyoid  to  the  thyroid  isthmus,  it 
is  not  unreasonable  to  regard  these  little  bodies  as  remnants 
of  this  remarkable  tube. 

2.  Lateral  Accessory  Thyroids. — The  thyro-glossal  duct 
is  not  responsible  for  all  accessory  thyroids,  for  they  occa- 
sionally arise  in  connection  with  the  germs  of  the  lateral 
lobes  of  the  thyroid.  This  variety  is  most  commonly  found 
in  the  neighbourhood  of  the  greater  cornua  of  the  hyoid. 

Accessory  thyroids  are  in  the  main  innocent  structures, 
but  occasionally  they  give  rise  to  troublesome  tumours.  It  is 
well  known  that  when  the  thyroid  body  becomes  goitrous, 
and  accessory  thyroids  co-exist,  the  latter  will  enlarge 
and  become  in  fact,  goitrous.  Apart  from  this,  accessory 
thyroids  will  enlarge  on  their  own  account  and  give  rise  to 
tumours  that  closely  simulate  unilateral  enlargement  of  the 
thyroid,  and  occasionally  give  rise  to  bronchoceles  of  moderate 
dimensions. 

Pollard*  has  carefully  described  a  tumour  removed  by 
Barker  from  the  anterior  triangle  of  the  neck  of  a  man  aged 

*  Trans.  Path.  Soc,  vol.  xxxvii.  507. 


316  DERMOIDS. 

thirty-five  years  ;  tlie  tumour  was  cystic,  and  from  its  inner 
wall  numerous  villous  processes,  covered  with  a  single  layer 
of  cubical  epithelium,  projected  into  the  cavity. 

The  Infundibulum  and  Pituitary  Body. — The  close 
structural  relationship  of  the  glandular  portion  of  the  pitui- 
tary body  to  the  thyroid  gland  makes  it  desirable  to  describe 
tumours  of  this  structure  in  sequence  with  those  connected 
with  the  thyro-glossal  duct.  The  infundibulum  arises  as  a 
diverticulum  from  the  first  encephalic  vesicle,  and  ends 
blindly  in  the  substance  of  the  pituitary  body.  This  body 
also  comes  into  relationship  with  a  diverticulum  from  the 
developing  pharynx  known  as  the  pouch  of  Rathke.  Although 
the  pouch  and  the  infundibulum  come  into  close  relation- 
ship with  the  pituit'Sry  body,  they  do  not  communicate  with 
each  other.  Dermoids,  adenomata,  and  cysts  are  met  with  in 
connection  with  these  structures  : — 

1.  Dermoids. — Bowlby*  described  a  tumour  as  large  as  a 
walnut  of  the  pituitary  body,  composed  of  vascular  connective 
tissue,  spaces  lined  with  epithelium  and  bone,  in  a  man 
twenty-two  years  old.  Hale  Whitef  met  with  one  the  size  of 
a  nut ;  it  contained  besides  connective  tissue,  vessels,  fat  cells, 
nerve  fibres,  ganglionic  cells,  and  striped  muscle  fibres.  The 
patient  was  a  boy  twelve  years  old. 

2.  Adenomata. — These  resemble  in  structure  the  thyroid 
gland,  and  bear  much  the  same  relation  to  the  pituitary 
body  that  parenchymatous  goitres  do  to  the  thyroid  body; 
indeed,  they  are  sometimes  referred  to  as  pituitary  goitres. 
A  few  cases  have  been  observed  in  man.  J  Gooclhart§  described 
an  interesting  case  in  a  baboon,  with  its  clinical  history ;  and 
Sibley  II  observed  a  specimen  in  an  ewe. 

These  tumours  are  at  first  isolated  from  the  general  cavity 
of  the  cranium  by  the  circular  fold  of  the  dura  mater  known 
as  the  diaphragma  sellce,  and  they  generally  produce  erosion 
of  the  pituitary  fossa.     As  they  increase  in  size,  tumours  of 

*  Trans.  Path.  Soc,  vol.  xxxvi.  35. 
■f-  Trans.  Path.  Soc,  vol.  xxxvi.  37. 

J  "Wills,  Brain,  vol.  xv.  465;  Loeb  and  Arnold,  Virchow's  "  Archiv," 
bd.  Ivii.  172. 

§  Trans.  Path.  Soc,  vol.  xxxvi.,  36. 
II  Trans.  Path.  Soc,  vol.  xxxix.  459. 


TUBTJLO-DEBMOIDS.  317 

the  pituitary  body  usually  implicate  the  optic  chiasma  and 
the  third  pair  of  nerves,  thus  producing  visual  disturbances. 
Sometimes  the  tumour  will  bulge  upwards  into  the  third 
ventricle. 

3.  Cysts. — When  the  pouch  of  Rathke  persists  it  some- 
times dilates  and  forms  a  cyst  in  the  pharynx  near  the 
junction  of  the  posterior  wall  with  the  roof.  Such  cysts  have 
been  known  to  reach  the  size  of  a  ripe  cherry ;  usually  they 
are  very  much  smaller.  Laryngologists  sometimes  regard 
them  as  sources  of  inconvenience,  and  attack  them  with  the 
galvano-cautery.  A  cyst  in  this  situation  as  large  as  a  cherry 
would  doubtless  impede  nasal  respiration  and  cause  the 
breathing  at  times  to  be  unpleasantly  audible. 


318 

CHAPTER    XXXIV. 

TUBULO-DERMOIDS  (continued). 

DERMOIDS   OF   THE    RECTUM. 

In  order  to  appreciate  the  nature  of  dermoids  arising  in  the 
immediate  neighbourhood  of  the  rectum,  it  will  be  necessary 
to  consider  a  few  points  connected  with  the  embryology  of 
this  portion  of  the  alimentary  canal.  In  the  early  embryo, 
the  central  canal  of  the  spinal  cord  and  the  alimentary  canal 
are  continuous  around  the  caudal  extremity  of  the  notochord. 
This  passage,  which  brings  the  developing  cord  and  gut  into 
such  intimate  union,  is  known  as  the  neurenteric  canal. 
When  the  proctodseum  invaginates  to  form  part  of  the  cloacal 
chamber  it  meets  the  gut  at  a  point  some  distance  anterior 
to  the  spot  where  the  neurenteric  canal  opens  into  it ;  hence 
there  is  for  a  time  a  segment  of  intestine  extending  behind 
the  anus,  and  termed  in  consequence  the  "  post-anal  gut." 
Afterwards  this  post-anal  section  of  the  embryonic  intestine 
disappears,  leaving  merely  a  trace  of  its  existence  in  the  small 
structure  at  the  tip  of  the  coccyx  known  as  the  coccygeal 
body.  There  is  good  reason  to  regard  the  post-anal  gut  as 
the  source  of  that  variety  of  congenital  sacro-coccygeal  tumour 
which  was  named  by  Braune*  and  several  writers  who  followed 
him  "  congenital  cystic  sarcoma."  These  tumours  will  be 
referred  to  as  thyroid-dermoids.  In  addition  it  will  be 
necessary  to  consider  dermoids  situated  between  the  rectum 
and  the  hollow  of  the  sacrum — post-rectal  dermoids — and 
certain  pedunculated  tumours  situated  within  the  rectum — 
rectal  dermoids. 

Thyroid-dermoids  in  structure  resemble  the  thyroid  body, 
for  they  are  composed  of  closed  vesicles  lined  with  glandular 
epithelium,  and  contain  glue-like  fluid.  Many  of  these 
tumours  are  composed  of  cysts  and  duct-like  passages  lined 
with  cubical  epithelium,  held  together  by  richly  cellular 
connective  tissue.  In  many  situations  the  epithelium  is 
columnar,  set  upon  flatter  cubical  cells.     The  cysts  are  filled 

*  Die  Uoppelhilclungen,  1S62. 


TUB  ULO-DEB,MOIDS. 


319 


with  ropy  mucus,  and  vary  in  size  from  a  nutshell  to  the 
smallest  space  visible  to  the  naked  eye ;  many  contain 
intracystic  processes.  These  tumours  present  such  very 
definite  characters  that  they  are  sure  to  attract  attention, 
and  their  large  size  makes  them  very  conspicuous.  (Figs. 
149  and  150.) 

Middeldorpf*  was  the  first  to  associate  clearly  a  congenital 
sacro-coccygeal  tumour 
with  the  post-anal  gut. 
His  specimen  was  re- 
moved from  the  neigh- 
bourhood of  the  anus 
of  a  girl  a  year  old. 
The  tumour  contained 
connective  tissue,  mu- 
cous membrane  with 
characteristic  follicles, 
submucous  tissue,  lon- 
gitudinal and  circular 
layers  of  muscle  fibres. 
I  had  come  to  the  same 
conclusion  in  regard 
to  the  probable  origin 
of  these  tumours  before 
the  publication  of 
Middeldorpfs  paper ; 
his  case  is  the  most 
conclusive  on  record. 
Alexander  Mackay,"!-  in 
a  pamphlet,  gives  accounts  of  two  cases  in  which  he  suc- 
cessfully removed  two  of  these  tumours  from  female  infants 
aged  two  and  a  half,  and  three  months  respectively,  at 
Huelva. 

Post-rectal  dermoids  are  very  rare,  and  do  not  form  such 
large  projecting  masses  as  the  preceding  species.  In  many 
instances  they  are  not  noticed  until  after  infant  life,  and  their 
clinical  tendencies  are  of  a  different  character.  It  is  also 
somewhat  remarkable  that  dermoids,  although  they  are  met 

*  Virchow's  "  ArcMv,"  M.  101,  s.  37. 
f  "  Surgery  in  Spain,"  1889. 


Fig.  149. — Thyroid-dennoid.    [HiLtchinson.) 


320 


BERMOIDH. 


with  in  many  parts  of  the  body,  contain  teeth  only  in  certain 
situations  ;  the  post-rectal  region  comes  into  this  category. 

The  museum  of  the  Middlesex  Hospital  contains  an 
example  of  post-rectal  dermoid  which  contains  hair  and 
teeth ;  the  specimen  is  without  history,  and  it  probably 
occurred  as  a  post-mortem  surprise. 

Such  tumours  sometimes  occur  as  surgical  surprises. 
Thus  a  lad  aged  nineteen  years  was  under  Bryant's  care  for  a 

discharging  sinus  on  the 
ventral  aspect  of  the  coccyx, 
which  had  existed  since  he 
was  three  years  old.  When 
this  was  explored  a  tumour 
was  found  between  the  rec- 
tum and  coccyx.  When  re- 
moved it  was  as  large  as  an 
orange,  and  consisted  of 
loculi  filled  with  pultaceous 
material,  and  contained  a 
piece  of  bone.  The  cysts 
were  lined  with  columnar 
epithelium. 

Post  -  rectal  dermoids 
sometimes  attain  very  large 
dimensions,  and  extend 
upwards  behind  the  pelvic 
peritoneum  in  men  and 
women. 
Ord*  described  a  case  in  which  a  dermoid  weighing  fourteen 
and  a  half  pounds  was  found  in  the  pelvis  of  a  man  twenty- 
eight  years  of  age.  The  tumour  contained  pultaceous  material 
mixed  with  hairs.  The  inner  wall  of  the  cyst  was  lined  with 
piliferous  skin ;  it  contained  sebaceous  glands. 

Frederick  Paget  has  described  a  case  in  which  he  removed, 
through  an  incision  across  the  space  between  the  anus  and 
coccyx,  a  large  post-rectal  dermoid  which  occupied  the  hollow 
of  the  sacrum  in  a  woman  forty-seven  years  of  age.  The 
tumour  lay  behind  the  rectum  and  peritoneum.     On  opening 

*  Med.-Chir.  Trans.,  vol.  Ixiii.,  p.  1. 

f  Brit.  Med.  Journal,  1891,  vol.  i.,  p.  406. 


Fig.  150. — Tliyroid-dermoid  of  tlie  coccj'geal 
region,  in  section.    {After  Shattock.) 


T  UB  UL  0-DERMOIDS. 


321 


the  cyst  putty -like  material  mixed  with  hair  was  removed  by 
means  of  a  spoon ;  the  cyst  was  then  enucleated.  The  cyst  and 
contents  weighed  three  pounds.  When  dried  and  stuffed  it 
assumed  an  ovoid  form  measiu'ing  76  cm.  in  circumference  in 
one  direction,  and  44  cm.  in  the  other.  The  patient  recovered. 

Rectal  Dermoids. — Several  examples  of  dermoid  tumours 
have  been  described  growinff  from  the  mucous  membrane  of 
the  rectum :  a  curious  feature  in  these  cases  is  that  the 
tumours  are  furnished  with  long  locks  of  hair,  which  protrude 
from  the  anus  and  annoy  the 
patients.  Like  post  -  rectal 
dermoids,  they  sometimes 
contain  teeth. 

The  case  described  by 
Port*  may  be  selected  as  a 
typical  specimen.  (Fig.  151.) 
The  tumour  was  removed 
from  the  rectum  of  a  girl 
sixteen  years  of  age.  It 
measured  5  cm.  in  the  long 
and  about  4  cm.  in  its  short 
axis.  It  was  covered  with 
skin  furnished  with  hair  and 
glands :    it   also   presented    a 

tooth.  The  bulk  of  the  tumour  was  made  up  of  fat  and 
fibrous  tissue.  Danzel  f  observed  a  similar  tumour  in  a  woman 
twenty-five  years  of  age.  It  was  as  large  as  an  apple,  and 
was  said  to  contain  brain  substance  enclosed  in  a  bony 
capsule;  a  tooth  projected  from  it.  (Fig.  152.)  This  woman 
was  troubled  with  long  hairs  which  protruded  at  the  anus 
and  she  used  to  pull  them  out  with  her  hands. 

Glutton  I  exhibited  a  specimen  at  the  Pathological  Society 
which,  in  conjunction  with  Floyer,  he  had  removed  from 
the  rectum  of  a  girl  nine  years  of  age.  The  patient  had  on 
two  occasions  been  troubled  with  tufts  of  hair  projecting 
from  the  anus.  Two  of  these  tufts  measured  25  cm.  The 
tumour,  after  removal,  measured  about  7  cm.  in  its  longest 

*  Trans.  Path.  Soc. ,  vol.  xxxi.,p.  307. 

f  Langenbeck's  "Arcliiv,"  bd.  xvii.,  s.  442. 

X  Trans.  Path.  Soc,  vol.  xxxvii.  252. 


151. — Rectal  dermoid  in  section. 
[After  Port.) 


322 


DEBMOIBS. 


diameter.  In  its  general  characters  it  resembled  the  two 
specimens  figured  (Figs.  151  and  152).  It  appears  to  have 
been  attached,  however,  at  a  higher  point  in  the  rectum. 

The  student  should  compare  rectal  with  pharyngeal  der- 
moids :  it  is  somewhat  curious  that  pedunculated  dermoids 


Fig.  152. — Kectal  dermoid.     {After  Darnel. 


should  be  peculiar  to  the  two  extremities  of  the  alimentary 
canal.  It  was  formerly  suggested  that  rectal  dermoids  of  this 
character  originated  in  the  ovary,  and  afterwards  invagi- 
natecl  the  rectum,  finally  presenting  themselves  at  the  anus. 
No  one  can,  with  our  present  knowledge,  seriously  advocate 
this  theor}^  Pedunculated  dermoids  growing  from  the  wall 
of  the  rectum  must  not  be  confounded  with  those  ovarian 
dermoids  which  erode  the  wall  of  the  rectum,  then  suppurate 
and  discharge  their  contents  into  it. 


323 


CHAPTER  XXXV. 

TUBULO- DERMOIDS    {concliiclecl). 

BRANCHIAL    FISTUL^i    AND    CYSTS. 

Since  1875,  when  Rathke  found  evidence  in  the  embryos  of 
pigs,  horses,  and  chicks,  of  the  branchial  clefts  so  characteristic 
of  fish,  many  eminent  anatomists  have  confirmed  his  observa- 
tions. Rathke  was  also  fortunate  enough  to  detect  the 
fissures  in  an  early  human  embryo.     (Fig.  153.) 

It  appears  that  in  1789  Hunczowski*  described  two  cases 
of  congenital  fistulous  openmgs  in  the  side  of  the  neck.  In 
1829,  Dzondi  described  similar  openings  under 
the  name  of  tracheal  fistulte ;  and  Ascherson, 
three  years  later,  showed  that  such  fistulte 
communicated  with  the  pharynx  and  not 
with  the  trachea. 

Heusinger,t  in  1864,  collected  a  number  of 
recorded  cases,  and  was  the  first  clearly  to    maiian  embryo,  show- 

,         ■  .      ,  .       ,  .  ing  the  gill-clefts. 

associate  these  congenital  cervical  openings 
Avith  the  branchial  clefts  detected  by  Rathke.  It  has 
been  asserted  by  His,  and  in  this  he  has  been  followed  by 
other  writers,  that  the  supposed  clefts  are  merely  furrows 
between  the  arches  ;  the  furrows  being  visible  on  the  inner  as 
well  as  on  the  outer  surface,  but  they  are  separated  from  each 
other  by  membrane.  This  view,  as  will  be  shown  afterwards, 
is  not  in  harmony  with  facts. 

The  human  embryo  has  four  branchial  clefts.  Of  these,  the 
first  becomes  the  tympano-Eustachian  passage,  and  the  three 
posterior  clefts  usually  suffer  obliteration.  Frequentl}^  one  or 
more  of  the  clefts  persist  wholly  or  in  part,  and  are  then 
known  as  "  congenital  cervical  fistulas."  These  fistulge  appear 
as  fine  canals,  capable  of  admitting  a  bristle,  and  some  a 
fine  probe.  The  orifice  usually  opens  in  the  neck ;  but  when 
complete  into  the  pharynx  also.  There  is  reason  to  believe 
that  they  may  open  into  the  pharynx,  but  end  externally  as  a 

*  Fischer,  "Deutsche  Zeitsch.  fiir  Chir.,"  bd.  ii. 
•f  Virchow's  "  Archiv,"  bd.  xxix.,  358. 


;24 


BEUMOIDS. 


cul-de-sac.  One,  two,  or  three  fistula;  may  be  present  in  the 
same  individual ;  they  have  a  great  tendency  to  be  bilateral, 
to  affect  several  members  of  the  same  family,  and  to  be  trans- 
mitted to  several  generations.  The  canals,  which  may  vary 
in  length  from  2  to  5  cm.,  are  lined  by  mucous  membrane, 
sometimes  with    ciliated   epithelium,  or   by  skin  containing 


Fig.  154. — Diagram  to  indicate  the  orifices  of  persistent  brancliial  flstulte. 

sebaceous  glands.  The  lining  membrane  of  the  canal  usually 
secretes  a  thin  mucous  fluid,  which  may  become  increased 
during  catarrhal  conditions  of  the  respiratory  passages. 
Occasionally  the  canal  inflames  and  an  abscess  results,  which 
may  give  rise  to  considerable  pain  and  difficulty  in  deglutition. 
The  external  orifice  of  a  branchial  fistula  may  be  indicated  by 
a  tag  of  skin,  containing  a  piece  of  yellow  elastic  cartilage. 
These  cutaneous  processes,  or,  cervical  auricles,  as  they  are 
called,  are  of  sufficient  interest  to  require  separate  con- 
sideration (page  330). 

Neglecting  for  the  present  the  first  cleft — the  tympano- 
Eustachian  passage — it  may  be  convenient  to  consider  the 


TUBULO-DERMOIBS.  325 

situations  usually  occupied  by  these  iistulte  when  they  occur 
in  man. 

The  external  orifices  of  the  listulse  are  apt  to  vary,  but 
they  usually  open  in  the  positions  shown  in  Fig.  154.  The  first 
becomes  the  tympano-Eustachian  passage  :  the  second  opens 
close  behind  the  angle  of  the  jaw  anterior  to  the  line  of  the 
sterno-mastoid  muscle ;  in  a  few  cases  it  may  be  on  a 
level  with,  and  slightly  posterior  to,  the  lobule  of  the  pinna. 
The  third  is  situated  on  a  level  with  the  thyro-hyoid  space 
close  to  the  anterior  border  of  the  sterno-mastoid  ;  this 
position  is  very  constant.  The  fourth  usually  opens  near 
the  sterno-clavicular  articulation  ;  it  maj^  open  3  or  4  cm. 
higher  in  the  neck,  but  always  in  relation  with  the  anterior 
border  of  the  sterno-mastoid  muscle. 

The  internal  orifices  of  these  fistulas  may  be  indicated  in 
the  following  Avay.  The  second  opens  into  the  recess  con- 
taining the  tonsil ;  the  third  and  fourth  are  in  relation  with 
the  sinus  pyriformis.  To  reach  this  sinus,  a  fistula  corre- 
sponding to  the  third  cleft  must  pass  over  the  loop  formed 
by  the  superior  laryngeal  nerve.  Hueter's*  observation  is 
interesting  in  this  connection :  "  In  a  young  fellow  who 
wished  to  become  a  trumpeter  I  dissected  out  one  of  these 
fistulous  tracks,  following  it  between  the  two  carotids  to  the 
pharyngeal  cavity." 

Prof  His  is  of  opinion  that  when  these  fistulas  com- 
municate with  the  pharynx,  it  is  the  result  of  incautious 
sounding.  I  have  satisfied  myself  that  these  fistulse  do  open 
into  the  pharynx  in  cases  where  no  probe  has  been  passed. 
This  I  have  demonstrated  by  allowing  a  child  with  a  second 
cleft  persistent  to  swallow  milk ;  drops  of  milk  found  their 
way  through  the  fistula  and  appeared  on  the  skin  of  the 
neck. 

Abnormal  persistence  of  branchial  clefts  occurs  in  four 
forms : — 

1.  Complete  fistula. 

2.  The  external  half  persists. 

3.  The  internal  half  persists. 

4.  The  external  and  internal  orifices  are  obliterated  but 

an  intermediate  section  persists. 

*  "  Grundriss  der  Chirurgie,"  vol.  ii.,  328,  1st  edition. 


326  DERMOIDS. 

The  first  form,  complete  fistiihe,  as  far  as  my  own  obser- 
vations extend,  occurs  most  frequently  in  connection  with  the 
second  cleft.  In  one  case,  a  youth  aged  fifteen  years,  the 
communication  with  the  pharynx  was  so  complete  that  when 
he  swallowed  milk  some  of  the  fluid  occasionally  passed 
through  the  fistula  and  appeared  at  the  cutaneous  orifice. 
In  another  case,  that  of  a  little  girl  acred  ten,  saliva  issued  at 
the  cervical  orifice  when  the  child  had  been  talking  freely, 
and  excited  the  parotid  gland. 

The  second  set  of  cases,  those  with  external  openings,  but 
blind  internal^,  are  the  most  common  examples,  and  need 
no  further  comment. 

The  third  class  are  rarely  recognised ;  this  is  not  remark- 
able when  we  remember  that  they  open  into  the  pharynx,  but 
end  externally  as  cul-de-sacs.  Heusinger  was  of  opinion  that 
some  pharyngeal  diverticula  are  of  this  nature,,  and  Sir  James 
Paget  refers  to  the  probability  that  some  rare  instances  of 
diverticula  from  the  phar3''nx  may  be  regarded  as  dilatations 
of  portions  of  branchial  fistula3,  closed  externally,  but  remain- 
ing open  within.  The  most  remarkable  case  of  this  nature 
that  has  been  placed  on  record  is  the  specimen  that  occurred 
in  the  body  of  an  adult  male  dissected  in  the  University  of 
Edinburgh,  and  described  by  Morrison  Watson  *  (Fig.  155). 

A  tube,  terniinating  inferiorly  in  a  cul-de-sac  containing  a 
large  quantity  of  grumous  material,  was  found  extending 
from  the  pharynx,  immediately  behind  the  tonsils,  to  the 
interclavicular  notch.  This  tube  possessed  muscular  walls, 
and  in  the  deep  part  of  its  course  passed  between  the  fork 
of  the  carotids  and  over  the  loop  of  the  superior  laryngeal 
nerve  ;  its  lower  part  was  parallel  with  the  anterior  border  of 
the  sterno-mastoid  muscle ;  it  rested  on  the  sterno-hyoid  and 
sterno-thyroid  muscles.  It  communicated  with  the  pharynx 
by  means  of  a  slit-like  opening,  not  more  than  3  mm.  in 
length,  the  margins  of  which  were  so  closely  in  contact  that 
the  entry  of  solid  particles  into  it  from  the  mouth  must  have 
been  prevented.  The  diverticulum  itself  increased  in  calibre 
from  above  downwards,  so  that  whilst  at  the  upper  end  a 
croAv-quill  could  with  difficulty  be  introduced,  at  the  lower  a 
pencil  could  readily  be  passed  along  the  lumen  of  the  tube. 

*  Journal  of  Anatomy  and  Pliysiohgy,  vol.  ix.,  p.  134. 


TUB  ULO-BEEMOID^. 


327 


It  is  further  noteworthy  that  the  pharyngeal  orifice  was 
situated  between  the  lower  jaw  and  the  stylo-hyoid  ligament. 
Its  point  of  departure  from  the  pharynx  corresponds  to  the 
supratonsillar  fossa.     The  muscle  fibres  were,  for  the  most 


Fig.  155.— Pharyngeal  diverticulum.    {After  Morrison  Watson.) 


part,  red  and  striated,  and  the  mucous  lining  resembled  that 
of  the  (Esophagus. 

The  fourth  class,  those  closed  at  each  end,  leaving  a 
portion  of  unobliterated  canal  in  the  neck,  cannot  be  recog- 
nised except  by  the  effects  to  which  they  give  rise. 

It  has  long  been  suspected  that  the  so-called  sebaceous 
cysts  which  occasionally  occur  in  the  neck,  below  the  deep 
cervical  fascia,  take  origin  in  unobliterated  branchial  spaces. 


328 


DEJiMOIDH. 


and  arc  deniioids.  A  convincing  case  of"  this  kind  is  de- 
scribed by  Virchow.*  A  woman  aged  twenty-four  had  noticed, 
since  the  age  of  fourteen,  a  tumour  between  the  angle  of 
the  jaw  and  the  mastoid  process.  When  she  came  under 
observation  it  was  of  the  size  of  a  goose's  Qgg,  there  was 
also  a  small  tumour  immediately  above  the  sternum,  which 
she  would  not  allow  to  be  removed.  The  larger  tumour 
was  extirpated,  and  found  to  contain  sebaceous  matter  and 


Fig.  156. — Head  and  neck  of  a  young  woman,  sliowing  branchial  fistulas  in  the  neck, «; 
and  a  sinus  in  tlie  helix,  A  ;  for  &,  see  text.     {After  Heusinger.) 

epidermal  scales.  The  wall  of  the  cyst  was  covered  with 
epidermis,  and  sebaceous  glands  were  disseminated  in  it. 

Lingual  dermoids  lying  between  the  mylo-hyoid  and 
genio-hyo-giossi  muscles  most  probably  arise  in  a  partially 
obliterated  second  branchial  cleft. 

A  retention  cyst,  arising  in  a  partially  obliterated  branchial 
cleft,  need  not  necessarily  contain  sebaceous  matter,  it  may 
be  filled  with  mucus.  This  apparent  contradiction  is  capable 
of  easy  explanation.  The  internal  segment  of  a  branchial 
fistula  is  lined  by  mucous  membrane  continuous  with  that 
of  the  pharynx,  whilst  its  external  segment  is  a  continu- 
ation of  the  surface  epithelium  of  the  neck.      It  is  on  this 

*  "  Archiv."  bd.  xxxv.  208,  1866. 


TITBULO- DERMOIDS.  329 

account  that  some  branchial  listulte  possess  ciliated  epithe- 
lium, others  squamous,  and  so  forth.  If  a  cystic  dilatation 
arise  in  connection  with  the  inner  segment,  a  cavity  with 
mucous  contents  would  be  the  result,  whilst  in  a  similar  cyst 
arising  from  the  external  segment  epidermal  scales,  sebaceous 
matter,  and  cholesterine  would  be  expected.  As  far  as  my 
own  observations  go,  mucous  cysts  originating  in  this  manner 
attain  larger  dimensions  than  the  dermoid  varieties.  Cervical 
cysts  arise  in  other  ways,  and  the  chapter  on  hydrocele  of 
the  neck  should  be  studied  in  relation  with  this  subject. 

In  the  copy  of  Heusinger's  sketch  (Fig.  156)  we  find  a  clear 
space  indicated  by  the  letter  h,  which  is  thus  described  in  the 
original :  "  Immediately  above  the  opening  is  a  slight  eleva- 
tion of  normal-coloured  skin."  In  Knox's  translation  of 
Dzondi's  paper  the  translator  remarks  that  in  many  persons, 
in  the  region  where  fistulse  have  been  observed,  he  had 
noticed  one  or  more  discoloured  spots,  which  spots  are  either 
rounded  and  of  a  pale  red  colour,  or  brownish,  or  like  subtile 
stria3  of  hairs,  superior  in  whiteness  to  the  surrounding  skin, 
but  conspicuous  only  to  very  sharp  sights.  I  have  occasionally 
found  these  spots  referred  to  by  Knox  in  persons  with 
branchial  fistulse ;  they  are  not  infrequent  near  the  angle 
of  the  jaw,  and  correspond  to  the  external  orifice  of  the 
second  cleft. 

Examples  of  persistent  branchial  clefts  have  been  observed 
in  horses  and  sheep.  Heusinger*  has  described  examples 
in  horses ;  they  open  immediately  below  the  pinna,  and  are 
noticed  more  frequently  in  carriage  than  in  draught  horses, 
as  the  secretion  from  the  fistula  soils  the  surrounding  skin 
and  attracts  the  attention  of  the  grooms.  An  example  of 
such  a  fistula  in  a  sheep  is  illustrated  in  Fig.  172  (page  349), 
and  corresponds  in  position  to  a  persistent  second  branchial 
cleft  in  the  horse. 

*  "  Deutsche  Zeitschiift  fiii-  Thiermedicin,"  bd.  ii.  1,  187G. 


330 

CHAPTER  XXXVI. 

DEKMOIDS. 

CERVICAL   AURICLES. 

In  describing  branchial  listulte  in  the  preceding  section  it  was 
mentioned  that  the  cutaneous  orifices  are  in  some  cases  sur- 
mounted by  tags  of  skin.     These  tags,  or  processes,  sometimes 


Fig.  157. ^Cervical  auricles  in  a  cliild. 

occur  luiassociated  with  jtistula3,  but  always  in  situations 
where  fistulse,  when  present,  open  on  the  skin.  Usually  they 
are  short,  in  some  cases  mere  nodules,  but  in  others  form 
prominences  2  to  3  cm.  in  height.  These  processes  have  been 
described  under  a  variety  of  names,  and  classed  among 
tumours,  but  at  the  present  time  they  are  commonly  known 
as  cervical  auricles. 

Like  branchial  fistul?e,  they  are  always  congenital,  and 
sometimes  affect  several  members  of  a  family.  The  mother 
may  have  a  cervical  auricle,  and  one  of  her  children  a 
branchial  fistula,  whilst  another  child  may  have  an  auricle 


CERVICAL    AURICLES. 


331 


associated  with  a  fistula ;  they  are  often  symmetrical. 
(Fig.  157.)  A  cervical  auricle  consists  of  an  axis  of  j^ellow 
elastic  cartilage  which  sometimes  extends  deeply  into  the 
tissues  of  the  neck ;  muscle-fibres  from  the  platysma  are 
attached  to  the  cartilage,  and  the  whole  is  surmounted  with 
skin  containing  hairs  and  sebaceous  glands. 


A  small  arterial 


Fig.  158. — Head  and  neck  of  a  goat  with  cervical  auricles. 


twig  runs  into  the  auricle  and  ramifies  in  the  fibrous  tissue 
and  fat  in  which  the  cartilao-e  is  embedded. 

Thus,  structurally,  cervical  auricles  are  identical  with  the 
normal  auricle  or  pinna,  and  they  agree  with  the  pinna 
morphologically,  inasmuch  as  they  are  developed  like  it 
from  that  portion  of  a  branchial  bar  which  is  directly  in 
relation  with  the  corresponding  cleft. 

■  In  sharks  the  gill-slits  open  separately  on  the  surface  of 
the  body ;  from  the  branchial  bar,  anterior  to  each  slit,  a 
fold  of  skin  is  formed  which  closes  upon  the  slit  like  a  lid,  and 
is  named  from  this  resemblance  the  operculum.  In  mam- 
malian embryos  a  slight  prominence  or  tubercle  is  for  a  time 
visible  anterior  to  each  of  these  clefts.     In  most  cases  the 


332 


DEBMOIJJH. 


tubercles  disappear  from  the  posterior  bars,  but  those  in 
relation  with  the  anterior  cleft  enlarge  and  are  joined  b}' 
accessory  tubercles  to  form  the  pinna.  Thus  embryology  has 
taught  me  to  regard  the  pinna  as  consisting  mainly  of  an 
operculum  which  has  become  modified  for  acoustic  purposes, 
for  we  may  regard  the  tubercles  formed  in  relation  with  the 
branchial  clefts  of  man  as  representatives  of  the  opercula  of 


i- 


Fig.  159.— Horned  sheep  with  cervical  auricles. 

certain  Icldliyopsida.  As  the  pinna  is  mainly  derived  from 
opercular  tubercles,  and  cervical  auricles,  in  all  probability, 
represent  persistent  opercular  tubercles,  it  is  reasonable  to 
term  them  cervical  auricles. 

The  homology  of  at  least  a  part  of  the  pinna  and  cervical 
auricles  with  the  opercula  of  fish  has  been  made  clearer  by 
Schwalbe's*  discovery  of  auricular  tubercles  in  the  embryo 
of  the  turtle  {Emys  livtaria  taurica)  ;  in  the  adult  condition 
chelonians  have  no  vestige  of  auricles. 

Cervical  auricles  occur  in  mammals  other  than  man. 
Heusinger,  in  1876,  mentioned  the  frequency  Avith  which 
pendulous  tags  of  skin  occur  in  the  necks  of  pigs,  goats,  and 
sheep,  yet  very  little  has  been  done  to  extend  his  observations. 
As  a  matter  of  fact  these  pendulous  bodies  are  extremely 
common  in  the  necks  of  goats. 

*  "Uber  Auiicularhocker  bei  Reptilien."  Anat.  Anzeiger,  vi  Jahrgang,  1891,  Nr.  2. 


GEBVIGAL    AURICLES. 


333 


The  anatomy  of  these  auricles  in  the  goat  is  similar  to 
that  of  cervical  auricles  in  man  :  there  is  an  axis  of  yellow 
elastic  cartilage  embedded  in  fibrous  tissue  and  fat,  the  whole 
being  covered  with  hairy  skin.  In  size  they  are  very  variable, 
and  in  the  goat  from  which  the  drawing  (Fig.  158)  was  made 
the  auricles  were  unusually  large. 

Cervical  auricles  are  occasionally  present  in  sheep,  and  a 


Fig.  160. — Head  of  a  pig  with  cervical  auricles  (the  Bell-pig  of  Australia) . 

good  specimen  is  sketched  in  Fig.  159.  The  most  remarkable 
examples  of  cervical  auricles  in  sheep  are  those  associated 
with  a  persistent  second  branchial  fissure.     (See  page  172.) 

In  Great  Britain  cervical  auricles  are  rare  in  pigs,  but 
Professor  Anderson  Stuart  has  drawn  attention  to  the  exist- 
ence in  Australia  of  a  breed  of  pigs  known  as  the  Bell-pig, 
on  account  of  the  presence  in  the  neck  of  pendulous  folds  of 
skin  in  the  neck.  It  may  here  be  mentioned  that  in  Germany 
these  auricles  in  sheep  and  pigs  are  known  as  glockchen  oder 
Berlocken.  The  sketch  of  the  Bell-pig  was  obtained  from  the 
stuffed  head  of  a  pig  which  Professor  Stuart  was  good  enough 
to  bring  me  from  Sydney  (Fig.  160).  The  original  I  presented 
to  the  museum  of  the  Royal  College  of  Surgeons. 


334 


DERMOID,^. 


Before  concluding  the  subject  of  cervical  auricles  reference 
must  be  made  to  the  presence  of  these  appendages  on  the 
necks  of  satyrs.  My  friend  Mr.  Shattock  drew  my  attention  to 
this  matter.  In  the  statues  of  many  satyrs  we  find  in  the 
neck,  in  the  situation  where  cervical  auricles  are  usually  found, 


Fig.  161. — Faun  and  goat,  with  (cervical  auricles. 


prominences  which  in  their  variety  of  form  resemble  the  cer- 
vical auricles  of  goats  and  men.  In  the  segipans  (goat-footed 
satyrs)  the  auricles  in  the  neck  are  pointed  like  their  ears,  and 
are  sessile,  but  in  the  fauns  they  are  usually  pendulous.  In 
the  statues  of  many  satyrs,  both  fauns  and  fegipans,  no  auricles 
are  represented,  and  they  are  less  constant  in  modern  than  in 
ancient  statues  of  fauns,  and  in  some  they  are  unilateral. 

It  is   an  interesting  subject  for  speculation  whether  the 
sculptors  obtained  their  notion  of  the  cervical  auricles  from 


CERVICAL    AURICLES. 


335 


hiinian  iiiodels  or  from  goats.  The  pendulous  forms  were 
probably  copied  from  goats.  This  is  well  illustrated  in  the 
faun  from  the  Capitol  (Fig.  161),  for  we  see  at  his  side  a  goat 
with  unmistakable  auricles,  and  a  goat's  skin  is  thrown  over  the 
faun's  shoulders.  The  hircine  element  in  the  comj)osition  of 
these  my thicah satyrs  is  evident  in  more  ways  than  one.  The 
segipans  are  goat-legged,  and  their  tails,  as  well  as  those  of 
their  fabled  sensual  relatives,  the  fauns,  are  excellent  copies  of 
goats'  tails. 

A   study  of  many  satyrs  induces  me  to  believe  that  some 


Fig.  162. — Two  drawings  representing  the  development  of  the  auricle.     {Modified  from  His.) 


A   good 


of  the  auricles  are  copies  from  human  models 
instance  of  this  is  a  marble  head  in  the  Glyptothek  at 
Munich,  described  as  "The  head  of  a  laughmg  faun."  In 
this  S23eciinen  the  auricle  is  unilateral  and  identical  in 
shape  with  those  in  the  necks  of  children. 


AURICULAR   DERMOIDS   AND    FISTULA. 

We  may  assume  that  the  auricle  or  pinna  consists  mainly 
of  an  enormously  developed  operculum  which  has  become 
utilised  for  acoustic  purposes.  It  has  already  been  pointed 
out  that  in  the  embryo,  each  branchial  cleft  is  surmounted  by 
a  swelling  or  tubercle  corresponding  to  the  operculum  of  the 
shark.  In  mammals,  and  as  Schwalbe  has  shown,  in  reptiles, 
the  first  cleft,  which  ultimately  becomes  modified  into  the 
tympano-Eustachian  passage,  is  surrounded  by  additional 
tubercles,  some  of  which  belong  to  the  mandibular  and  others 
to  the  hyoid  bar.  (Fig.  162.)  It  is  by  the  subsequent  growth 
and  coalescence  of  these  tubercles  that  the  auricle  is  formed. 


386 


DFAlMOfDH. 


These  tubercles  have  received  the  following  iiamcs  from 
His*  : — I.,  tuberculum  tragiciim  ;  ii.,  tuberculuiii  anteriiis ; 
III.,  tuberculum  intermedium ;  iv.,  tuberculum  anthelicis ; 
v.,  tuberculum  antitrasj^icum  ;  and  vi.,  lobulus. 

The  subsequent  fate  of  these  tubercles  may  be  briefly 
given.  The  tuberculum  tragicum  unites  across  the  cleft, 
with    the     tuberculum     antitragicum,    the    space     formerly 


Fig.  163. — Congenital  fistula  in  the  Iielix.     (After  Paget.) 


separating  them  being  simply  indicated  by  the  incisura  inter- 
tragica.  The  tuberculum  intermedium  is  the  source  of  the 
helix,  whilst  the  tuberculum  anthelicis  furnishes  the  anthelix ; 
the  nodule  vi.,  cut  off  by  the  fusion  of  tragus  and  antitragus, 
becomes  the  lobule. 

Imperfections  in  the  development  and  union  of  these 
tubercles  will  serve  to  explain  several  congenital  defects  to 
which  the  auricle  is  liable.  Of  these,  three  are  of  especial 
interest : — (1)  Auricular  fistulte  ;  (2)  dermoids  ;   (3)  accessory 


tragus. 


*  Aiiaf.  Men.  Einhrj/oiicii,  1885,  heft.  iii. 


CERVICAL    FISTULJE. 


337 


1.  Auricular  Fistulas. — Heusinger  seems  to  have  been 
the  hrst  to  describe  a  congenital  fistula  in  the  helix. 
(Fig.  156.)  For  the  tirst  complete  account  of  these  fistuhe 
in  England  we  are  indebted  to  Sir  James  Paget."^'  The 
fistula  usually  appears  as  a  small  opening  leading  into  a  canal 
ending  blindly  in  the  substance  of  the  helix.  The  auricle 
may  be  of  good  shape,  but  often  it  is  deformed.  (Fig.  163.) 
Usually  a  small  quantity  of  greasy  material  exudes  from  the 


Fig.  164.— Dermoid  of  the  auricle  and  uaevus  of  the  palpebral  conjunctiva. 
{After  Lanneloncjue.) 

orifice  of  the  sinus,  which  varies  from  2  to  6  mm.  in  depth 
These  fistuhe  sometimes  exist  in  individuals  who  also  have 
branchial  fistuLe ;  or  one  member  of  a  family  will  have  a 
congenital  fistula  in  the  auricle,  and  another  a  congenital 
fistula  in  the  neck ;  they  are  hereditary. 

It  is  far  rarer  to  find  consrenital  fistulas  in  the  lobule. 
Very  few  examples  have  been  observed.  A  little  girl 
(daughter  of  a  friend)  was  born  with  a  perforation  in  the 
lobule  of  the  left  auricle  exactly  in  the  spot  for  wearing  an 
earring,  and  to  this  day  she  wears  a  ring  in  this  lobule  and 
refuses  to  have  the  other  pierced. 

The  facts  now  at  our  disposal  enable  us  to  understand 
how  such  fistulas  arise,  for  it  seems  reasonable  to  conclude 
that  if  the  various  lobules  which  conspire  to  form  an  auricle 

*  Med.-Chii-.  Trans.,  vol.  Ixi.,  p.  41,  1878. 


338  DERMOIDS. 

unite  imperfectly,    the   intervening  spaces  would    persist    as 
sinuses  or  fistulte. 

(2)  Auricular  Dermoids.  —  From  what  has  just  been 
stated  regarding  the  probable  mode  of  origin  of  auricular 
fistulte,  it  will  be  obvious  that  if  unobliterated  skin-lined 
spaces  are  left  between  the  tubercles  uniting  to  form  the 
auricle,  and  the  skin  lining  such  spaces  possesses  glands 
(sequestrated  tracts  of  skin  are  unusually  rich  in  sebaceous 
glands),  we  have  in  such  a  space  a  potential  dermoid. 

The  auricle  is  not  an  uncommon  situation  for  cysts  often 
described  as  sebaceous  ;  usually  they  are  small, 
but  sometimes  attain  the  dimensions  of  a 
cherry  or  even  larger.  When  these  supposed 
sebaceous  cysts  are  examined  microscopically 
they  sometimes  turn  out  to  be  dermoids  (Fig. 
164).  It  is  a  curious  fact  that  unless  small 
dermoids  in  unusual  situations  are  very 
cautiously  examined,  they  run  a  great  chance 
of  being-  put  aside  as  sebaceous  cysts. 

Pig.      166.  -  Auricle  .       ^.       1  n  •  n  r.      r.   •  ■ 

with  an  accessory  Auricuiar    deriXLOids    01    lair   size    some- 

tragus.  .  11- 

tmies  occupy  the  groove  between  the  pmna 
and  the  mastoid  process ;  if  allowed  to  grow  they  will  form  a 
deep  hollow  in  the  underlying  bone. 

(3)  Accessory  Tragus. — One  of  the  commonest  malforma- 
tions of  the  pinna  is  reduplication  of  the  tragus.  The  accessory 
tragus  is  extremely  variable  in  form ;  often  it  assumes  the 
form  of  a  low  conical  projection  in  front  of  or  above  the 
tragus  (Fig.  165);  sometimes  it  is  pedunculated  and  hangs  as 
a  small  cutaneous  tag  slightly  in  front  of  the  tragus,  beset 
with  pale  delicate  hair. 

Occasionally  an  accessory  tragus  is  associated  Avith  a 
circular  cicatrix-like  depression  in  the  cheek  immediately  in 
front  of  the  pinna.  It  is  a  fact  of  some  interest  that  mal- 
formations of  the  tragus,  and  the  presence  of  an  accessory 
tragus,  are  often  associated  with  defects  in  the  mandibular 
fissure,  such  as  macrostoma,  mandibular  fistula,  and  tubercle. 
This  association  is  shown  in  Figs.  130,  131  and  1,79. 


339 


CHAPTER     XXXVII. 

DERMOIDS    (concluded). 

OOPHORITIC   (ovarian)   CYSTS.* 

Ovarian  Cysts,  formerly  included  in  one  genus,  comprise 
four  distinct  species.  Of  these,  three  species,  parovarian  cysts, 
paroophoritic  cysts,  and  ovarian  hydroceles,  are  considered  in 
Group  IV.  In  this  chapter  we  have  to  deal  with  those  cysts 
to  which  the  term  ovarian  strictly  applies,  and  as  they  arise 
in  the  oophoron,  or  egg-bearing  portion  of  the  ovary,  it  will 
avoid  confusion  to  refer  to  them  as  orjphoritic  cysts.  Of 
these  there  are  three  varieties  :  — 

1.  Simple  oophoritic  cysts. 

2.  Ovarian  adenomata. 

3.  Ovarian  dermoids. 

1.  Simple  Oophoritic  Cysts. — These  may  be  unilocular 
or  multilocular.  When  the  cysts  are  large  it  is  difficult  to 
demonstrate  an  epithelial  lining  on  the  interior  of  the  loculi, 
but  in  their  early  stages  they  have  a  membrana  granulosa. 
When  they  attain  the  size  of  a  melon  stratified  epithelium 
may  be  sometimes  demonstrated.  In  very  large  cysts,  such 
for  instance,  as  have  a  capacity  of  one  or  more  gallons,  the 
walls  consist  of  fibrous  tissue  only,  the  epithelium  atrophies 
from  the  pressure  to  which  it  has  been  subjected. 

2.  Ovarian  Adenomata. — These  are  always  multilocular. 
They  have  a  fibrous  capsule  through  which  the  various  loculi 
project  and  produce  a  lobulated  surface.  On  section  the 
tumour  displays  a  honeycomb  appearance,  the  loculi  of  which 
are  of  various  shapes  and  sizes  ;  many  do  not  exceed  1  cm.  in 
diameter,  others  are  as  large  as  melons.  These  cavities  are 
filled  with  viscid  fluid  identical  in  its  physical  characters 
with  mucus.  The  walls  of  many  of  the  smaller  loculi  are 
covered  with  a  regular  layer  of  tall  columnar  epithelium ; 
many  of  them  contain  in  addition  complex  mucous  glands, 

*  In  this  work  the  characters  of  ovarian  cysts  are  only  briefly  described, 
as  they  are  considered  very  fully  in  my  work  on  Surgical  "Diseases  ofj,the 
Ovaries." 


340 


DERMOIDS. 


and  others  are  indistinguishable  from  ovarian  foIHcles.  When 
these  tumours  are  fresh,  if  some  of  the  smaller  loculi  are 
punctured  with  a  knife  and  the  fluid  watched  as  it  flows 
through  the  opening,  a  small  opaque  body  about  the  size  of  a 
rape-seed  will  be  detected;  it  floats  on  the  mucus  like  the 
cicatriculum  on  the  yolk  of  an  egg. 

3.  Ovarian    Dermoids.  —  A    very    large    proportion    of 
oophoritic   cysts   contains   skin   and   mucous   membrane,  or 


Fig.  166. — Mucous  membrane  from  an  ovarian  dermoid. 

both  these  structures,  and  one  or  many  of  the  appendages 
peculiar  to  them.  In  a  unilocular  cyst,  the  skin  or  mucous 
membrane  ma}^  line  it  throughout,  or  be  restricted  to  a  very 
small  area.  In  some  multilocular  cysts  one  cavity  will  be 
lined  with  skin,  whilst  others  possess  mucous  membrane ; 
many  are  filled  with  glandular  tissue,  and  others  have  an 
epithelial  lining  which  will  stand  for  skin  or  mucous  mem- 
brane. The  skin  in  an  ovarian  dermoid  may  be  bald,  or  it 
may  be  richly  furnished  with  cutaneous  appendages,  such  as 
hair,    sebaceous    glands,    sweat    glands,   mammge,    nippleless 


OVARIAN   DERMOIDS.  341 

mamnise,  and  nipples  without  mamma?.  Teeth  sometimes 
occur  in  prodigious  numbers  (300  have  been  counted) ;  un- 
striped  muscle-iibre,  dermal  bone,  and  bone  cancellous  in 
texture ;  horn  and  nail  are  occasionally  present,  and  very 
rarely  brain-like  tissue.  The  important  fact  to  bear  in  mind 
is  that  the  structures  found  in  dermoids  of  the  ovary  are 
always  those  normally  belonging  to  skin  or  mucous  mem- 
brane. Formed  organs,  such  as  limbs,  vertebrte,  long  bones, 
or  cranial  bones,  do  not  occur.  The  imaginatior  of  dis- 
sectors sometimes  leads  them  to  see  in  these  irregular  bony 
masses,  maxillse,  mandibles,  parietals,  etc.  ;  others  have  found 
perfect  foetuses,  but  these  were  calcified  extra-uterine  foetuses 
(lithopsedia).  In  past  times  ovarian  dermoids  have  been  mis- 
taken for  extra-uterine  foetuses,  and  vice  versa.  Such  errors, 
now  unpardonable,  gave  colour  to  the  parthenogenetic  theory 
of  ovarian  dermoids.  No  one  has  demonstrated  liver,  heart, 
lungs,  intestine,  kidney,  bladder,  etc.,  in  an  ovarian  dermoid. 

Oophoritic  cysts,  simple,  adenomatous,  or  dermoid,  some- 
times attain  prodigious  proportions — fifty,  sixty,  and  one 
hundred  pounds.  A  cyst  with  its  contents  has  been  known 
to  weigh  one  hundred  and  sixty  pounds  (Cullingworth). 
Oophoritic  cysts  occur  at  all  ages,  from  the  seventh  month  of 
foetal  life  to  the  eighty-fourth  year.  There  is  no  satisfactory 
record  of  the  dermoid  variety  having  been  observed  before  the 
end  of  the  first  year  of  life. 

Secondary  Changes. — Three  accidents  to  which  ovarian 
cysts  are  liable — viz.,  axial  rotation,  rupture,  and  suppuration 
— must  be  considered. 

Axial  Rotation. — Ovarian  cysts,  in  common  with  many 
varieties  of  pedunculated  cysts,  are  liable  to  rotate  on  their 
axes,  a  movement  which  leads  to  torsion  of  the  pedicle  and 
consequent  interference  with  the  circulation  of  the  tumour. 
When  the  torsion  is  acute,  severe  pain  and  venous  engorge- 
ment are  the  usual  effects ;  when  the  rotation  occurs  slowly,  it 
may  so  completely  arrest  the  venous  and  arterial  current 
through  the  pedicle  that  growth  is  stopped,  and  in  exceptional 
cases  the  cyst  slowly  atrophies.  In  a  small  proportion 
of  cases  the  life  of  the  tumour  is  preserved  in  consequence  of 
adhesions  it  acquires  to  surrounding  tissues,  especially  omen- 
tum.    When  this  happens  the  original  connections  of  the  cyst 


342 


DERMOIDS. 


with  tlic  uterus  are  gradually  severed,  and  its  nutrition  is 
derived  from  the  omentum  in  virtue  of  new  vessels  formed  in 
the  adhesions.  When  an  operation  is  carried  out  for  the 
removal  of  such  a  tumour  the  surgeon  is  surprised  to  find  an 

Omeiitnm.  Fallopian  tube. 


Fig,  167. — Ovarian  dermoid  detached  from  the  uterus  and  hanging  from  the  omentum. 
(Removed  by  Sir  George  Humphry.) 

ovarian   dermoid   with    a   Fallopian   tube  hanging  from  the 
omentum,  unconnected  with  the  uterus.     (Fig.  167.) 

Rupture. — When  simple  ovarian  cysts  rupture,  the  bland 
fluid  they  contain  rarely  gives  offence  to  the  peritoneum ;  it  is 
quickly  absorbed  and  excreted  by  the  kidneys.  When  ovarian 
dermoids  rupture,  the  richly  cellular  contents  are  scattered 


OVARIAN   DERMOIDS.  343 

over  the  peritoneuni  and  give  rise  to  grave  disturbance.  The 
most  interesting  event  that  follows  the  intraperitoneal  rup- 
ture of  an  ovarian  dermoid  is  the  appearance  of  secondary 
dermoids  on  the  peritoneuni.  This  rare  form  of  epithelial 
infection  may  take  the  form  of  mmute  granules  on  the  peri- 
toneum, each  of  which  is  furnished  with  a  tuft  of  delicate 
lanugo-like  hair,*  or  they  may  give  rise  to  tumours  as  large  as 
cherries  or  even  Tangerine  oranges.  These  may  hang  from 
the  under  surface  of  the  liverf  or  form  clusters  like  "  cherries 
upon  a  branch,"  J  or  be  embedded  in  adhesions  between 
coils  of  intestine.  This  mode  of  dissemmation  of  dermoids 
is  analogous  to  the  epithelial  infection  of  the  peritoneum 
occasionally  observed  with  paroophoritic  cysts. 

Suppuration. — When  air  or  intestinal  fluids  gain  access  to 
ovarian  dermoids,  then  suppuration  with  all  its  attendant  evils 
is  the  result.  Contamination  may  also  arise  from  punctures 
with  trocars  or  aspirating  needles.  More  frequently  it  is  due 
to  entrance  of  fluids  from  the  intestine,  due  to  adhesion  of  the 
bowel  to  some  part  of  the  cyst-wall,  with  subsequent  thinning 
of  the  adherent  parts  until  the  septum  becomes  so  thin  that 
osmosis  of  intestinal  fluids  occurs  and  fouls  the  cyst.  When 
suppuration  happens,  the  pus  may  find  an  outlet  through  the 
rectum,  vagina,  or  bladder.  Sometimes  a  sinus  forms  in  the 
anterior  abdominal  wall,  and  it  is  not  rare  in  such  cases  for 
the  pus  to  point  at  the  umbilicus. 

THE    NATURE  OF  THE  OVARIAN   FOLLICLE  AND   THE  MUTABILITY 
OF   SKIN   AND   MUCOUS   MEMBRANE. 

Oophoritic  cysts  of  the  three  varieties  discussed  m  the 
first  part  of  this  chapter  arise  in  ovarian  follicles.  The  re- 
remainder  of  this  chapter  will  be  devoted  to  the  consideration 
of  the  nature  of  the  ovarian  follicle  and  to  the  relation- 
ship of  skin  and  mucous  membrane ;  it  will  also  be  necessary 
to  discuss  briefly  the  mutability  of  epithelium. 

The  Nature  of  the  Ovarian  Follicle. — The  phylogeny  of 
the  ovarian  follicle  is  intimately  bound  up  with  the  history  of 
the  peritoneum.     The  pleuro-peritoneal  cavity  in  most  verte- 

*  Kolaczek,  Vii-chow's  "  Archiv,"  bd.  Lxxv.  399. 

f  Hulke,  Trans.  Path.  Soc,  vol.  xxiv.,  157. 

X  Fraenkel,  JVien.  Med.  Wochenschrift,  1883,  p.  865. 


344  DERMOIDS. 

brates  arises  as  a  schizocoele,  due  to  the  splitting  of  the  lateral 
walls  of  the  embryo  into  splanchno-plenre  and  somato-pleure. 
This  mode  of  origin  is  secondary,  for  in  simpler  forms  the 
eoelom  (pleuro-peritoneal  cavity)  is  derived  from  abstrictions 
of  the  archenteron.  Thus  the  ccelom  is  a  derivative  of  the 
primitive  gut,  and  its  surface  is  covered  with  epithelium.  The 
cells  of  the  genital  ridge,  which  form  ova  and  line  the  follicles, 
are  of  the  same  nature  as  those  which  give  rise  to  mucous 
glands  in  the  intestine.  Morphologically,  an  ovarian  follicle 
is  a  modified  mucous  gland. 

It  will  be  necessary  to  discuss  the  relationship  of  skin  and 
mucous  membrane.  Skin  covers  the  exterior  of  the  body, 
and  possesses  in  addition  to  the  horny  layer  a  rete  nuicosum 
containing  pigment.  In  many  animals  it  furnishes  protective 
structures  such  as  scales,  horns,  scutes,  quills,  bristles,  feathers, 
hair,  etc.,  all  of  Avhich  are  modifications  of  the  epidermis  or 
its  papillary  processes.  Glands  derived  from  the  surface 
epithelium  may  furnish  mucus,  poisonous  fluids,  and  milk.  • 
Subject  as  skin  is  to  external  modifying  influences  (environ- 
ment) ,  we  need  not  express  surprise  at  the  variety  of  structure 
and  modification  exhibited  by  it.  Mucous  membrane  in  its 
most  typical  form  exists  in  the  intestine.  It  has  a  single 
layer  of  columnar  epithelium,  which  may  be  ciliated  (amphi- 
oxus,  petromyzon,  ammoccetes).  The  epithelium  dips  into 
the  underlying  tissue  to  form  nmcous  glands. 

Instead  of  intestinal  mucous  membrane,  let  us  select  a 
piece  from  the  buccal  cavity.  Here  we  find  it  lined  with 
layers  of  flattened  epithelium  surmounting  papillas ;  some  of 
these  papillse  are  calcified  and  form  teeth.  Many  rodents  have 
hairy  patches  on  the  buccal  aspect  of  the  cheek.  In  dogs  the 
mucous  membrane  of  the  mouth  contains  pigment ;  this  is 
occasionally  the  case  with  the  lingual  mucous  membrane  in 
man ;  and  the  vagina  sometimes  contains  tracts  of  blue  pig- 
ment in  monkeys.  Sebaceous  glands  are  not  peculiar  to  skin  ; 
they  are  large  and  numerous  in  the  mucous  membrane  of  the 
nymphse,  and  occasionally  in  the  lips.  Mucous  glands  occur 
in  the  skin  of  batrachians,  worms,  and  as  slime  glands  in  fish. 

In  snails,  oysters,  mussels,  etc.,  the  mantle  secretes  a 
shell ;  in  reptiles,  and  such  specialised  vertebrates  as  birds,  the 
glands  in  the  mucous  membrane  of  the  oviduct  perform   a 


OVABIAN   DERMOIDS. 


345 


similar  function ;  calcareous  formations  resembling  shells  are 
constantly  formed  by  the  glands  in  the  prostate  of  man. 

A  single  layer  of  epithelium  avails  little  in  the  argument, 
for  worms  have  a  single  layer  of  columnar  epithelium  to  their 
skin.  Amphioxns  is  similarly  provided  in  the  gastrula  stage, 
the  cells  being  ciliated.  It  has  been  urged  that  the  lining 
membrane  of  the  mouth  is  practically  skin,  inasnmch  as  it  is 
derived  from  the  epiblast,  and  it  has  been  said  that,  to  render 
the  argument  valid,  hair  should  be  found  on  the  mucous 
membrane  lining  the  stomach  or  intestine.  Such  is,  in  fact 
the  case,  in  the  re- 
markable bird,  the 
Darter  {Plot  a.s 
a n li  in  fj a)  ;  its 
pyloric  orifice  is 
guarded  by  a  tuft 
of  hair.* 

It  is  well  to 
bear  in  mind  that 
skin     in    at    least 

-,         ,•  ,1  Fis.  lOS. — Ovum  in  its  follicle  :  from  a  cat.     (After  Klein.) 

one  situation — the         °  y  j  > 

conjunctiva — has  become  modified   into  mucous   membrane 
and  not  rarely  reverts  to  its  original  form.     (See  page  355.) 

It  used  to  be  taught  that  epithelium  was  very  stable,  but 
we  know  that  the  cohimnar  variety  is  very  mutable.  When 
exposed  to  external  influences  and  pressure  it  quickly  grows 
stratified.  Examples  have  been  mentioned  (page  130).  The 
cohimnar  cells  of  the  intestine  become  stratified  at  the  margin 
of  a  colotomy  wound,  or  on  the  exposed  surface  of  a  pile,  and 
the  change  from  columnar  to  stratified  epithelium  occurs 
normally  on  the  dorsal  wall  of  the  cat's  trachea,  in  con- 
sequence of  the  overriding  of  the  extremities  of  cartilaginous 
semi-rings  under  the  influence  of  the  trachealis  muscle. t 

In  order  to  appreciate  the  high  potentiality  of  the  mem- 
brana  granulosa  it  should  be  studied  in  the  cat  (Fig.  168), 
then  the  student  will  cease  to  wonder  whence  the  tall 
columnar  epithelium  so  characteristic  of  an  ovarian  adenoma 
(Fig.  166)  is  derived. 

*  "  The  Collected  Works  of  Garrod,"  p.  334. 

■j-  Haycraft  and  Carlier,  Quart.  Jour.  Micros.  Sci.,  vol.  xxx.,  519,  1890. 


346 


CHAPTER    XXXVIII. 

PECULIARITIES     IN     THE     DISTRIBUTION     OB^     CUTANEOUS 
APPENDAGES     IN     DERMOIDS. 

In  the  preceding  chapters  the  various  species  of  dermoids  are 
arranged  in  their  respective  genera  and  their  chief  clinical 
features   indicated.     It   will  now  be  useful  in  bringing  this 

.p   ,...:--:. ^ 


Fig.  169. — Magnitied  section  of  an  ovarian  dermoid,  to  show  tlie  large  size  of  the 
sebaceous  glands. 

section  to  a  conclusion  to  draw  attention  to  some  peculiarities 
in  the  ^distribution  of  cutaneous  appendages  found  in  der- 
moids. The  distinguishing  feature  of  dermoids  is  the  presence 
of  skin  or  mucous  membrane,  and  the  structures  found  in 
these  tumours  are  those  normally  associated  with  skin  or 
mucous  membrane. 

Hair  is  the  most  frequent  of  the  many  cutaneous  append- 
ages in  dermoids  and  occurs  in  all  the  genera.  In  the  case  of 
man  it  is  identical  with  that  which  grows  on  other  parts  of 
the  body  ;  but  its  colour  is  capricious,  and  usually  bears  little 


HAIB    lA^   DERMOIDS. 


347 


relation  to  that  on  the  body  of  the  individual.  In  an  ovarian 
dermoid  from  a  negress  the  hair  ma}^  be  curly,  but  light-brown 
in  colour.  In  other  animals  dermoids  contain  hair  or  wool 
according  to  the  nature  of  the  tegumental  covering.  It  is 
said  that  in  birds  they  contain  feathers ;  I  have  never  had 

Twisted,  pedicle. 


Fig.  170.  — Ovarian  dermoid  with  a  sebaceous  adenoma,  from  a  woman.     It  contained 
hair,  but  its  walls  were  bald. 

an  opportunity  of  verifying  this  statement.     Dermoids  in  pigs 
contain  bristles. 

It  is  a  curious  fact  that  hair  in  sequestration  dermoids  is 
rarely  longer  than  3  cm.,  whereas  in  ovarian  dermoids  it  is 
often  15  or  20  cm.  long,  and  a  specimen  1"50  m.  (5  ft.)  long  has 
been  described  by  Munde.*  The  hair  on  rectal  dermoids  is 
sometimes  very  long.     In  all  genera  the  hair  may  become 

*  Am.  Journal  of  Ohstet.,  vol.  xxiv.  854. 


348 


DEBMOTDS. 


white  with  age,  and  in  elderly  individuals  a  hairy  dernioid, 
like  the  scalp,  may  become  bald..    (Fig.  170.) 

The  number  and  size  of  the  sebaceous  glands  in  dermoids 
are  very  variable.  The}^  are  numerous  and  well  formed  in 
almost  all  sequestration  dermoids,  but  attain  their  greatest  size 
in  ovarian  dermoids,  where  they  occasionally  form  a  pedun- 
culated tumour — a  sebaceous  adenoma.  (Fig.  170.)  The 
highest  variety  of  secreting  gland  found  in  these  tumours  is 


Fig.  171. — Ovarian  maiiinia  ;  hair  and  teetli  are  also  present.    {Museum,  Middlesex  Hospital.) 


a  mamma.  Ovarian  dermoids  sometimes  contain  nipple-like 
processes  of  skin  which  may  or  may  not  be  associated  with  a 
skin-covered  mass  of  fat,  shaped  like  a  mamma ;  exceptionally 
these  nipples  are  traversed  by  ducts  associated  with  glandular 
tissue  which  secretes  colostrum.  (Fig.  171.)  A  few  gland- 
containing-  colostrum-secreting  mammse  are  nippleless. 
Mammse  and  pseudo-mammas  are  peculiar  to  the  ovarian 
genus  of  dermoids. 

The  distribution  of  teeth  among  dermoids  is  somewhat 
curious.  So  far  as  my  observations  go  they  are  not  found  in 
the  sequestration  genus,  but  are  of  fairly  frequent  occurrence 
in  ovarian  dermoids,  and  .sometimes  are  present  in  prodigious 
numbers  (300).  Teeth  also  occur  in  rectal  and  post-rectal 
dermoids.     (Figs.  151  and  152.) 

Exceptionally  they  have  been  found  in  dermoids  arising 


OVARIAN    TEETH. 


349 


in  the  branchial  clefts.  This  is  a  matter  of  some  interest, 
because  teeth  are  sometimes  found  associated  with  persistent 
branchial  fistulas.  In  1890  I  exhibited  at  the  Pathological 
Society,  London,  an  example  of  a  persistent  second  branchial 
fistula  in  a  sheep  (Fig.  172) ;  it  was  surmounted  by  a  prominent 
cervical  auricle  beset  on  its  posterior  surface  by  a  number  of 
processes  resembling  the  buccal  papilke  of  sheep.     Protected 


Auditory jneatus 


Fistula 


Fig.  172.— Head  of  a  sheep  with  a  branchial  fistula,  cervical  auricle,  and  tooth. 
In  the  lower  figm-e  the  auricle  and  tooth  are  shown  of  natural  size. 

by  this  auricle  there  was  a  slender,  ill-formed,  incisor  tooth 
mounted  on  a  pedicle  of  bone,  surrounded  by  mucous  mem- 
brane.* It  is  preserved  in  the  museum  of  the  Royal  College 
of  Surgeons.  Kostanecki  f  has  since  pubHshed  an  account 
of  a  similar  specimen.     (See  also  Gurlt.  J) 

Teeth  are  occasionally  associated  with  the  second  branchial 

*  Trans.  Path.  Soc,  vol.  xlii.  477. 

t  Virchow's  "  Archiv,"  bd.  cxxiii.  401. 

X  Thierische  Missgehirten,  1877.     Taf.  xv. 


360 


DERMOIDS. 


cleft  in  horses.  These  specimens  throw  sonje  li^'ht  upon 
teeth  found  on  the  petrosal  bones  of  oxen,  of  which  some 
examples  are  preserved  in  the  Veterinary  Museum  at  Alfort, 
and  render  it  possible  that  some  of  the  curious  cases  of  cervical 
teeth  in  the  human  subject,  usually  described  as  errant  wisdom 
teeth,  belong  to  the  same  category. 

Teeth  in  dermoids  are  composed  of  dentine,  enamel  and 


Fig.  173.— The  germ  of  an  ovarian  tooth,  from  a  dermoid. 
E,  the  enamel-organ  ;  p,  dentine  papilla. 


cementum  arranged  in  the  same  manner  as  in  normal  teeth, 
and  developed  on  the  same  plan.     (Fig.  173.) 

The  consideration  of  glands  and  teeth  in  dermoids  would 
be  incomplete  without  an  account  of  those  peculiar  concentric 
bodies  known  as  epithelial  pearls.  These  bodies  vary  some- 
what in  structure  and  probably  arise  in  different  ways.  The 
common  form  of  epithelial  pearl  consists  of  concentric  laminse 
of  horny  epithelium  ;  the  central  portions  in  some  specimens 
are  structureless  and  transparent  like  horn  (Fig.  174);  in 
others  the  cells  are  large  and  distinct ;  in  some  the  epithelium 
forms  onion-like  layers  without  any  tendency  to  cornification. 

The  common  mode  by  which  epithelial  pearls  are  formed 
is  by  the  retention  and  subsequent  moulding  of  shed  epi- 
thelium in  the  recesses  of  sebaceous  glands,  in  mucous  crypts, 


EPITHELIAL    PEARLS. 


351 


or  in  folds  of  epithelial-covered  surfaces.  They  are  sometimes 
found  on  the  forehead  along  the  margin  of  the  hairy  scalp  ;* 
they  are  common  in  the  penis,  at  the  junction  of  the  prepuce 
and  glans,  and  in  the  tonsils  of  children. 

There  is  another  variety  which  occurs  in  situations  where 
epithelial  surfaces  become  fused  in  the  process  of  development, 
as,  for  example,  along  the  middle  line  of  the  hard  palate.     It 


\-'»<2 


^^gf./ 


^^&^M'^^^^' 


Fig.  174. — Epithelial  pearl.     (After  Kcmthaclc.) 

is  not  unusual  to  find  them  in  this  situation  in  children  at 
birth,  and  occasionally  they  will  be  found  hanging  by  short 
pedicles,  especially  in  the  neighbourhood  of  the  pre-maxillte. 
They  are  sometimes  met  with  on  the  under  surface  of  the 
penis. 

Epithelial  pearls  are  often  found  in  the  gums.  The  largest 
examples  that  have  come  under  my  notice  occurred  in  ovarian 
dermoids.  In  one  remarkable  specimen  Avhich  I  examined 
it  was  possible  to  trace  every  stage  between  a  typical  epithelial 
pearl  and  an  enamel-organ.  In  a  series  of  sections  some 
showed  the  ingrowth  of  epithelium  from  the  surface  of  a 
loculus ;  in  a  few,  pearls  were  visible  composed  of  large  epi- 
thelial cells  :  whilst  others  exhibited  laminse  of  horny  material 

*  See  remarks  on  Cholesteatoma,  p.  182. 


352  DEimoins. 

and  in  some  of  the  sections  a  developing  tooth  with  its  papilla, 
enamel-organ,  and  gubernaculum  could  be  seen.  These 
observations  suggested  that,  apart  from  the  retention  of  shed 
epithelium  and  the  inclusion  of  epithelium  between  opposed 
surfaces,  it  is  probable  that  pearls  may  arise  in  some  in- 
stances by  ingrowths  of  epithelium  on  the  principle  of  enamel- 
organs.  This  view  would  be  consistent  with  Kanthack's* 
observation  on  pearls  of  the  hard  palate,  to  the  effect  that 
when  a  series  of  sections  is  made  it  will  usuall}^  be  found 
that  the  pearl  is  connected  with  the  surface  by  a  tract  of 
epithelium.  This  is  further  interesting,  for  it  may  serve  to 
throw  some  light  on  meso-palatine  teeth.  It  is  well  known 
that  small  supernumerary  teeth  in  young  children  are  not 
uncommon  in  the  anterior  segment  of  the  meso-palatine 
suture.  These  teeth,  which  must  not  be  confounded  with  the 
occasional  third  incisor,  are  usually  lodged  in  the  nuicous 
membrane  only.  In  1890  I  ventured  to  suggest  that  meso- 
palatine  teeth  are  probably  associated  with  these  pearls.f 

*  Journal  of  Anatomy  and  Physiology,  vol.  xxv.  155. 
f  Trans.  Odont.  Soc.  Gt.  Britain,  vol.  xxii.  156. 


353 


CHAPTER  XXXIX. 


MOLES. 


Moles  are  pigmented  and  usually  hairy  patches  upon  the 
skin.  They  are  congenital  or  appear  during  the  first  few 
weeks   of  birth.     Moles   vary   greatly  in  size  ;  many  are  no 


Fig.  175. — Extensive  hairy  mole  upun  the  face  of  a  boy  a  year  old. 

larger  than  split  peas,  while  others  cover  an  extensive  area 
of  the  trunk,  face,  or  limbs. 

The  common  variety  consists  of  a  slightly  raised  patch, 
usually  brown  in  colour ;  but  it  may  be  quite  black,  and  is,  as 
a  rule,  covered  abundantly  with  hair.  As  moles  occur  in 
situations  where  hair  is  generally  scanty,  they  are  conspicuous 
objects.    The  hair  growing  upon  the  mole  is  commonly  short, 

X 


354 


DERMOIDS. 


like  that  upon  the  skin  covering  the  trunk  of  a  dog. 
Occasionally,  however,  it  is  as  long  as  that  naturally  found 
upon  the  scalp.  In  a  boy  a  year  old  I  have  seen  nearly  the 
whole  of  the  trunk  covered  with  a  niole,  and  the  hair  growing 
from  it  was  as  long  as  that  upon  his  head.  When  moles 
exist  on  the  forehead  they  sometimes  appear  to  be  an  exten- 
sion of  the  hairy  scalp.     The  hair  upon  moles  does  not  differ 


Fig.  176. — Extensive  hairy  mole  on  the  trunk  of  a  man,  47  years  of  age,  which  became  the 
seat  of  sarcoma,  from  which  the  patient  quickly  died.    (After  Lawson.*) 


from  hair  in  general,  and  is  furnished  Avith  sebaceous  glands  ; 
sweat  glands  are  present  when  the  mole  is  seated  on  a  part 
of  the  skin  where  these  glands  normally  exist.  The  amount 
of  pigment  varies  much ;  in  some  moles  it  is  so  abundant 
as  to  produce  an  inky  blackness.  Moles  are  always  very 
vascular ;  but  the  most  striking  feature  in  their  histology  is 
that  the  tissue  immediately  underlying  them  is  often  similar 
to  that  characteristic  of  an  alveolar  sarcoma. 

The  rarer  form  of  mole  consists  of  a  patch  of  black,  or 
deep-brown  pigment  overlying  tissue  similar  to  that  of  an 
alveolar  sarcoma.     These  patches  may  or  may  not  be  raised 

The  pigmented  area 


above  the  level  of  the  surrounding  skin. 


*  Trans.  Path.  Soc.,vol.  xxiv.  256. 


MOLES.  355 

contains  a  few  hairs  which  are  not  larger  or  longer  than  those 
in  the  immediate  neighbourhood  of  the  patch. 

Small  hairy  moles  do  not  as  a  rule  cause  much  incon- 
venience even  when  they  occur  on  the  face,  in  which  situation 
they  are  known  as  "beauty  spots."  As  many  as  fifty  moles 
may  be  present  on  one  individual.  When  a  mole  is  extensive, 
and  occurs  in  an  exposed  situation  (Fig.  175),  it  is  a  serious 
disfigurement.  When  very  large  moles  occur  on  the  trunk 
the  hairy  part  is  sometimes  very  sensitive,  almost  hyper- 
ffisthetic.  In  large  moles  pendulous  skin  folds  are  sometimes 
present ;  these  folds  are  large  in  the  young,  but,  as  a  rule, 
they  shrink  and  become  quite  small  in  the  adult. 

Moles  bleed  freely  when  their  surfaces  are  abraded  or 
incised.  They  are  also  liable  to  ulcerate  spontaneously;  the 
ulcerated  surface  bleeds  freely.  The  most  important  change 
to  which  they  are  liable  is  to  become  later  in  life  the  starting- 
point  of  melanomata,  some  of  which  are  very  infective,  and 
quickly  destroy  life.  (Fig.  176.)  The  relation  of  melanomata 
to  moles  is  considered  in  chapter  xiii. 

Moles  on  the  Conjunctiva. — The  mucous  membrane  lining 
the  ocular  surface  of  the  eyelids,  and  covering  the  cornea 
and  adjacent  portions  of  the  eyeball,  occasionally  presents 
patches  of  skin  which,  in  appearance  and  structure,  are 
identical  with  hairy  moles. 

These  dermoid  patches,  or  conjunctival  moles,  occur  most 
frequently  at  the  margins  of  the  cornea,  and  usually  in  the 
line  of  the  palpebral  fissure — that  is,  directly  in  the  equator 
of  the  cornea;  but  they  are  by  no  means  confined  to  these 
situations.  Usually  they  are  limited  to  the  conjunctiva 
covering  the  sclerotic,  or  trespass  but  little  on  the  cornea. 
Sometimes,  however,  they  involve  a  considerable  extent  of  the 
corneal  surface.     (Fig.  177.) 

Wardrop*  described  a  conjunctival  mole  in  a  man  fifty 
years  of  age ;  it  was  congenital.  Twelve  long  hairs  grew  from 
its  middle,  passed  between  the  eyelids,  and  hung  over  the 
cheek.  These  hairs  did  not  appear  until  the  sixteenth  year, 
at  which  time  the  beard  began  to  grow. 

Occasionally  a  mole  will  be  found  on  each  side  of  the 

*  "  Morbid  Anatomy  of  the  Human  Eye,"  1834. 


356 


DERMOWh'. 


cornea  in  the  line  of  the  palpebral  fissure.  A  very  rare 
variety  is  limited  to  the  caruncle.  A  good  example  is  depicted 
in  Fig.  178,  associated  with  an  eccentric  pupil.  This  is  simply 
an  excessive  development  of  the  delicate  hairs  that  normally 
beset  the  caruncle. 

These  moles  are  occasionally  associated  with  malformations 


Fig.  177.— Conjunctival  mole — common  variety. 


of  the  eyelids,  especially  the  one  known  as  coloboma  of  the 
upper  eyelid,  of  which  a  good  example  is  given  in  Fig.  179. 
When  this  association  occurs,  the  defect  in  the  lid  corresponds 


Fig.  178.— Mole  on  the  caruncle,  associated  with  an  eccentric  pupil.     (After  Demntirs.*) 

to  the  cutaneous  patch  on  the  conjunctiva.  This  combination 
is  of  some  iinportance  as  it  is  used  as  evidence  in  support  of 
an  explanation  that  has  been  put  forward  in  regard  to  these 
moles,  based  upon  the  development  of  the  eyelids. 

In  the  embryo  the  tissue  covering  the  outer  surface  of 
the  eyeball,  which  ultimately  becomes  the  conjunctiva,  is 
directly  continuous,  and  in  structure  is  identical  with  the  skin 
at  the  margin  of  the  orbit.     Very  early  cutaneous  folds  arise, 

*  Maladies  des  Yenx,  1818,  pi.  Ixiv.,  fig.  1. 


MOLES. 


357 


gradually  grow  over  tlie  surface  of  the  eyeball,  and  come 
into  apposition  at  a  spot  corresponding  to  the  future  palpebral 
fissure.  These  folds  ultimately  become  the  eyelids.  The  sur- 
faces of  these  folds,  which  are  continuous  with  the  covering  of 
the  eyeball,  become  converted  into  mucous  membrane,  and 
are  termed  conjunctiva.     In  every  normal  eye  the  conjunctiva 


Fig.  179. — Conjunctival  mole  associated  with  coloboma  of  the  eyelid,  a  mandibular  tubercle, 
and  accessory  tragus.    {Cowell's*  case). 

bears  evidence  of  its  transformation  from  skin,  inasmuch  as 
the  caruncle  at  its  inner  angle  is  furnished  with  delicate  hairs. 
It  is  reasonable  to  suppose  that,  as  the  occlusion  of  the  proper 
covering  of  the  eyeball  by  the  eyelids  is  the  cause  of  the  con- 
version of  the  conjunctiva  into  mucous  membrane,  if  from 
any  cause  a  part,  or  even  the  whole  of  it,  were  left  uncovered, 
the  exposed  part  would  persist  as  skin.  This  is  precisely 
what  occurs.  When  the  eyelid  is  in  the  condition  of  coloboma 
(Fig.  179) — a  defect  due,  in  all  probability,  to  the  imperfect 
union  of  the  embryonic  eyelid  to  the  skin  covering  the  fronto- 
nasal plate — a  piece  of  conjunctiva  persists  as  skin,  and  forms 

*  Trans.  OiDhthal.  Soc,  vol.  xi.,  p.  214. 


358 


])EUMOn)S. 


a  mole  occupying  the  gap  in  the  hcl.  Moles  occur  on  the 
conjunctiva  unassociated  with  colobomata,  but  in  nearly  every 
instance  they  are  situated  on  the  cornea  in  the  line  ot 
the  palpebral  fissure.  This  circumstance  would  indicate 
that  during  development  the  conjunctiva  was  imper- 
fectly covered  by  the  developing  lids.  It  should  be  re- 
membered that  in  many  eyes  exactly  in  the  situation  in 
which  moles  are  most  frequently  found,  slight  elevations  or 
Pingueculae  of  the  conjunctiva  occur.  These,  when  examined 
microscopically,  will  be  found  to  contain  epithelial  elements. 


Fig.  180. — Conjunctival  mole  in  a  sheep. 

In  a  few  very  exceptional  cases  the  eyes  have  been  found 
completely  covered  with  skin  without  any  traces  of  eyelids. 
Such  a  condition  is  known  as  cryptophthalmos,  and  the 
explanation  offered  concerning  it  is,  that  in  these  cases  the 
eyelids  have  failed  to  appear  and  in  consequence  the  con- 
junctiva has  persisted  as  skin. 

Conjunctival  moles  have  been  observed  in  horses,  sheep, 
oxen,  and  do2"s,  and  are  furnished  with  hair  or  wool  according 
to  the  nature  of  the  tegumentary  covering  characteristic  of 
the  mammal  in  which  they  occur.     (Fig.  180.) 


359 


CHAPTER    XL. 

THE   TREATMENT   OF   DERMOIDS. 


Dermoids  are  innocent  tumours.  Some  of  them  attain  a 
certain  size  and  then  cease  to  grow ;  others  will  remain,  as  it 
were,  torpid  for  years,  then,  without  any  obvious  reason, 
suddenly  resume  active  growth  and  reach  a  large  size  in  a 
comparatively  short  space  of  time.  Many,  and  perhaps  the 
majority,  steadily  grow  without  intermission,  uninfluenced  by 
the  rules  of  growth  which  govern  the  dimensions  of  organs  in 
general.  Thus  no  experience,  however  extensive,  will  enable  a 
surgeon  to  assure  a  patient  that  a  given  dermoid  will  remain 
quiescent,  or  that  it  will  become  a  large  tumour.  The  closest 
observation  by  the  best  observers  has  failed  to  detect  any 
laws  regulating  the  growth  of  dermoids  or  of  other  tumours. 
Take,  for  example,  dermoids  of  the  scalp,  or  those  at  the  angle 
of  the  orbit :  some  of  these  in  an  ordinary  lifetime  will  not 
exceed  the  dimensions  of  a  walnut,  yet  cases  are  known  in 
which  a  dermoid  of  the  scalp  has  grown  as  large  as  a  cocoa- 
nut.     (Fig.  142.) 

It  may  be  stated  generally  of  sequestration  dermoids  that, 
as  a  rule,  they  remain  of  small  size ;  but  many  exceptions 
occur.  (Fig.  122.)  Knowing  then,  the  potentiality  of  these 
tumours,  it  is  the  custom,  whenever  they  occur  in  accessible 
situations,  to  remove  them  early  in  infant  life. 

There  are  situations  where  the  removal  of  a  dermoid  is  not 
attempted — e.g.,  when  it  grows  between  the  laminas  of  the 
tentorium  cerebelli,  or  when  a  sternal  dermoid  invades  the 
mediastinum  or  pleura.  These  cases  are  in  the  main  post- 
mortem surprises. 

There  is  a  fact  that  should  not  be  overlooked  in  regard 
to  dermoids :  so  long  as  their  capsules  remain  intact  any  evil 
influence  they  exert  is  mechanical ;  but  when  from  any  cause — 
e.g.,  injury,  ulceration,  or  communication  with  a  hollow  viscus 
like  the  intestine,  bladder,  or  bronchus — putrefactive  organisms 
gain  access  to  their  contents,  rich  in  dead  organic  matter, 
decomposition  with  all  its  attendant  evils  is  the  result. 
This  is  well  illustrated  by  the  distressing  histories  of  patients 


360  DERMOIDS. 

with  ovarian  dermoids  that  have  coiriinunicated  with  the 
bladder. 

In  three  situations  dermoids  are  very  hable  to  destroy 
hfe  : — (1)  Intracranial  dermoids,  by  the  pressure  they  exercise 
on  the  brain ;  (2)  intrathoracic  dermoids,  by  interference 
with  the  lung;  (3)  pelvic  dermoids  which  lead  to  intestinal 
obstruction  by  pressing  on  the  rectum,  or  establish  urinary 
troubles  by  becoming  impacted  in  the  pelvis  and  compressing 
the  urethra  or  the  ureters,  or  lead  to  septicaemia  by  the 
decomposition  of  their  contents.  Occasionally  an  ovarian 
dermoid  interferes  with  delivery  and  causes  the  death  of  two 
lives,  mother  and  child. 

At  present  no  one  has  succeeded  in  removing  an  intra- 
cranial dermoid.  An  accurate  diagnosis  is  impossible,  but  it 
is  highly  probable  that  a  surgeon,  in  operating  for  an  intra- 
cranial tumour,  will  one  clay  find  himself  face  to  face  with  a 
dermoid. 

In  the  thorax  the  signs  are  usually  those  of  empyema 
until  "  hair-spitting  "  occurs.  The  successful  removal  of  an 
intrathoracic  dermoid  awaits  accomplishment,  whereas 
ovarian  dermoids  are  removed  successfully  almost  daily. 
Other  varieties  of  pelvic  dermoids,  especially  the  post-rectal 
species,  have  been  successfully  enucleated  by  Bryant,  Frederick 
Page,  and  W.  W.  Keen.     {See  page  320.) 

Pedunculated  rectal  dermoids  only  require  the  same  treat- 
ment as  polypi — viz.,  ligature  of  the  pedicle  and  detachment 
of  the  tumour.  The  large  tubulo-dermoids  found  in  the 
coccygeal  region  demand  considerable  judgment.  In  the 
majorit}''  of  cases  nature  disposes  of  the  diiSculty  either  by 
destroying  the  child's  life  before  it  is  born,  or  in  the 
process  of  delivery.  A  few  survive  this  event  for  some 
days  or  even  weeks.  Those  which  successfuU}''  escape 
these  disasters  are  brought  to  surgeons,  who  endeavour  to 
remove  the  tumours  when  they  are  satisfied  that  the  children 
are  strong  enough  to  be  submitted  to  this  ordeal.  Some 
successful  cases  have  been  reported  ;*  but  many  have  failed. 
I  collected  the  scattered  records  of  surgical  enterprise  in  this 
direction,  but  the  analysis  reveals  that  the  various  genera  of 
sacro-coccygeal  tumours  have  not  been  appreciated  by  surgeons; 

*  Mackay  wa?  successful  in  two  cases.      [See  p.  319.) 


TREATMENT  OF  DERMOIDS.  361 

so  that  it  is  difficult  to  decide  wlietlier  the  individual  cases 
were  dernioids,  tubulo-dermoids,  liponaata,  teratomata,  or 
spina  bifida  cysts.  Thus  the  facts  were  useless  for  the  purpose. 
It  is  to  be  hoped  that  future  records  will  be  more  precise. 

Dermoids  in  connection  with  the  mouth  do  not  offer  any 
difficulty  in  treatment.  Pharyngeal  dermoids  are  easily 
avulsed,  and  in  some  cases  have  become  spontaneously 
detached.  Palatine  dermoids  and  adenomata  may  be  easily 
enucleated  after  their  capsules  have  been  incised;  and  in 
removing  lingual  dermoids  it  is  only  necessary  to  take  care 
to  thoroughly  extirpate  every  portion  of  their  cyst-walls,  or 
troublesome  sinuses  will  remain. 

In  removing  a  dermoid  at  the  root  of  the  nose  the  surgeon 
must  not  be  surprised  to  find  the  capsule  running  deeply 
between  the  bones  in  that  situation,  and  it  not  infrequently 
rests  upon  the  dura  mater. 

The  treatment  of  the  various  deformities  connected  with 
the  fissures  about  the  face — such  as  hare-lip,  cleft  palate, 
coloboma  of  the  eyelid,  etc. — does  not  come  within  the 
scope  of  this  book.  It  will  be  necessary  to  consider  the 
treatment  of  branchial  fistulas,  median  cervical  fistulse, 
cervical  auricles,  etc. 

In  the  majority  of  cases  cervical  fistulse  give  no  trouble, 
but  there  are  instances  in  which  a  fistula  discharo-es  fluid 
so  as  to  become  a  source  of  annoyance,  or  it  gets  inflamed 
from  time  to  time.  Under  these  conditions  it  should  be 
dissected  out.  Such  operations  must  be  recommended  with 
caution,  as  these  fistulee  extend  deeply  into  the  neck  and  run 
in  very  intimate  relation  with  the  great  vessels  of  the  neck 
and  the  vagus  nerve. 

Attempts  to  obliterate  them  by  such  methods  as  the 
application  of  caustics,  heated  wire,  etc.,  are  worse  than 
useless.  In  removing  median  cervical  fistulas  it  is  necessary 
to  dissect  the  duct  quite  up  to  the  body  of  the  hyoid  bone 
to  ensure  its  thorough  eradication. 

Cervical  auricles  are,  in  most  children,  easily  dissected 
out.  When  the  auricle  has  connections  extending  to  the  deep 
surface  of  the  sterno-mastoid,  the  operation  requires  care. 

Hairy  moles,  when  smaU  and  in  situations  where  they 
cause    disfigurement,    should    be    excised.      When    carefully 


362  DERMOIDS. 

performed  the  operation  leaves  scarcely  a  scar.  Extensive 
moles  upon  the  trunks  and  limbs  are  beyond  treatment,  but 
in  the  case  of  a  large  hairy  mole  on  the  face,  it  is 
necessary  to  adopt  some  method  for  its  relief.  Great 
good  may  be  effected  by  the  ingenious  plan,  introduced  by 
Morrant  Baker,*  of  carefully  shaving  the  mole  with  a  sharp 
scalpel  so  as  to  remove  the  pigmented  portion  of  the  skin  and 
the  layer  that  contains  hair  bulbs.  The  operation  is  usually 
attended  by  free  but  easily  controlled  bleeding,  and  the  shaved 
surface  heals  without  the  formation  of  cicatricial  tissue. 
Should  some  of  the  hairs  persist  after  this  treatment  they 
may  be  destroyed  by  the  application  of  nitric  acid  and 
similar  caustics.  Such  an  extensive  mole  as  that  represented 
in  Fig.  175  is  unfortunately  beyond  the  reach  of  surgical  art. 

Small  conjunctival  moles  may  be  dissected  off  as  in  the 
case  of  a  ptergium ;  and  if  a  coloboma  of  the  lid  is  associated 
with  it,  the  edges  cleft  may  be  vivified  and  united  on  the  same 
principles  employed  in  the  treatment  of  hare-lip. 

*  Med.  Chir.  Trans.,  vol.  Ixi.  33. 


363 


CHAPTER   XLI. 

TERATOMATA. 

Strictly,  the   consideration   of  teratomata  belongs    to  that 
department  of  pathology  known  as  teratology ;  but  as  certain 


Raibca 


Doodica 


Fig.   ISl.— The   twin   sisters   Radica  and  Doodica    at  tlie  age  of  3^  years;    born  in 
18S9  at  Noapara,  a  village  in  the  province  of  Orissa,  India.* 

species  are  so  very  apt  to  be  confounded  with  dermoids,  it  is 
necessary  to  give  a  brief  account  of  them  here. 

A  teratoma  is  an  irregular  conglomerate  mass  containing 
the  tissues  and  fragments  of  viscera  of  a  suppressed  foetus 
attached  to  an  otherwise  normal  individual, 

*  Cf.  The  Medical  Week,  vol.  i.,  p.  11. 


364 


TERATOMATA. 


In  order  to  appreciate  the  nature  of  those  singular  mal- 
formations it  will  be  necessary  to  consider  the  subject  of 
conjoined  twins,  supernumerary  hmbs,  and  acarcliac  foetuses. 
In  the  animal  and  vegetable  kingdom  it  occasionally  happens 


Fig.  182. — Laloo,  a  Hindoo,  witli  an  acardiac  parasite  attached  to  iiis  thorax. 


that  a  single  ovum  gives  origin  to  two  embryos,  which  may 
be  quite  separate  from  each  other  or  they  may  be  united, 
a  condition  known  as  conjoined  twins.     (Fig.  181.) 

When  two  embryos  are  conjoined,  and  one  goes  on  to 
complete  development,  whilst  only  certain  parts  of  its  com- 
panion continue  to  grow,  the  result  is  a  parasitic  foetus.  The 
mature  individual  supporting  it  is  the  autosite.     (Fig.  182.) 

In  other  examples  the  suppressed  fcetus  consists  of  an 
irregular-shaped  tumour  growing,  perhaps,  from  the  posterior 


TEEATOMATA. 


365 


Fife.  183. — Cliick  witli  a  supernumerary  pair  of  legs  projecting  from  the  ventral  aspect 

of  the  pelvis. 


Fig.  184» — Chick  with  a  supernumerary  pair  of  legs  projecting  from  the  dorsal  aspect  of 
the  pelvis.     A,  anus  ;  a,  supernumerary  anus. 


^66 


TEBATOMATA. 


surface  of  the  sacrum,  or  within  the  abdoirien  or  thorax, 
which  on  dissection  contains  a  few  vertebrae,  or  processes  of 
skin  resembhng  digits,  associated  with  a  piece  of  intestine  or 
an  imperfect  hver.     This  is  a  teratoma. 

In  order  to  demonstrate  the  relation  between  parasitic 
foetuses  such  as  Fig.  182  and  teratomata,  it  will  be  useful  to 
refer  to  dichotomy.  In  animals  and  vegetables  there  is  a 
strong   tendency   for   parts    ending   in   free    extremities    to 

bifurcate  or  dichotomise.  When 
this  affects  digits  the  result  is 
supernumerary  lingers  and  toes. 
Should  it  extend  to  the  axis  of 
the  limb,  supernumerary  legs, 
wings,  or  fins  are  produced. 
Dichotomy  is  not  confined  to 
the  limbs,  but  affects  also  the 
axis  of  the  trunk.  When  the 
whole  embryonic  axis  dichoto- 
mises, twins  are  produced. 
Should  cleavage  be  partial,  and 
-p.    ,_    „      ,„         7  ,  ■  ^     •*,         affect   the   caudal   end   of    the 

Fig.   185. — Frog    (nana  palustris)    with     a 

supernumerary  hind  leg.     {After  Tud.-     truuk,   it   is    SpokeU    of    aS     pOS- 
erraan.)  _  _  -L  J-      _ 

terior  dichotomy.  When  it 
involves  the  anterior  end  it  is  called  anterior  dichotomy. 
With  complete  dichotomy  in  which  both  embryos  go  on  to 
full  development,  either  as  separate  or  conjoined  twins,  we  are 
not  further  concerned,  and  the  conditions  arising  from  the 
imperfect  growth  of  one  embryo  whilst  its  companion  con- 
tinues to  develop,  must  be  deferred  until  we  have  discussed 
the  results  of  partial  dichotomy. 

Posterior  Dichotomy. — When  cleavage  involves  the  caudal 
section  of  the  trunk  axis  to  any  serious  extent  it  necessarily 
follows  that  the  pelvis  as  well  as  the  vertebral  column  will  be 
reduplicated  :  it  is  also  obvious  that  the  reduplication  of  the 
pelvis  involves  a  corresponding  increase  in  the  number  of 
the  pelvic  organs,  including  the  limbs.  Thus  it  follows  that 
supernumerary  hind  limbs  may  arise  from  dichotomy  affecting 
the  embryonic  limb,  or  from  cleavage  of  the  caudal  end  of  the 
trunk.     The  two  modes  also  hold  good  for  reduplication  of 

*  Journal  of  Anatomy  and  Fhijsiology,Yo\.  xx.,  p.  516. 


TEBATOMATA. 


367 


the  fore  limbs.  The  conditions  and  positions  of  supernumerary 
Kmbs  due  to  posterior  cleavage  are  represented  by  the  chicks 
and  frog  in  Figs.  183,  184,  and  185.     Thus  the  hmbs  may 


Fig.  186. — Louise  L.,  dame  a  quatrejo.mhes.     {Ed.  Burjnion.) 

project  from  the  ventral  asj^ect  of  the  pelvis,  or  be,  as  it  were, 
dislocated  on  to  the  dorsal  surface,  as  in  Fig.  184.  Occasionally 
they  occupy  a  position  midway  between  these  two  extremes 
and  lie  more  or  less  parallel  with  the  normal  hind  limbs,  as  in 


368  TEBATOMATA. 

Fig.  185.  In  some  of  the  specimens  the  supernumerary  legs 
fuse  throughout  the  greater  part  of  their  extent,  and  in  some, 
one  leg  becomes  completely  suppressed.  It  is  a  noteworthy 
fact  that  in  all  specimens  of  supernumerary  limbs  due  to 
posterior  dichotomy  there  is  an  accessory,  but  usually 
imperforate,  anus. 

Supernumerary  hind  limbs  in  every  way  identical  with 
those  exhibited  by  the  chicks  occur  in  the  human  species.  A 
woman  with  an  extra  pair  of  limbs  identical  in  its  relations  to 


187.— Sacral  teratoma  with  a  superuuinerary  leg. 


the  pelvis  with  those  in  the  chick  (Fig.  183)  has  been  carefully 
described  by  Bugnion.*  (Fig.  186.)  In  this  case  the  woman 
could  not  initiate  any  movement  in  the  accessory  limbs, 
although  she  readily  localised  the  prick  of  a  pin  made  upon 
any  part  of  them ;  she  was  also  uncomfortable  when  the 
parasite  was  cold.  In  the  furrow  between  the  buttocks  of  the 
accessory  limbs  there  was  a  fossa  representing  the  imperforate 
anus  and  genital  orifice  of  the  parasite,  situated  about  12  cm. 
from  the  vulva  of  the  woman. 

An  example  corresponding  to  the  dorsal  limb  in  the  toad 
(Fig.  193)  is  represented  in  Fig.  187.  For  an  opportunity  of 
studying  this  rare  condition  I  am  indebted  to  Dr.  Matthews 
Duncan  and  Mr.  H.  Huxley.     It  was  a  female  child  ;  over  the 

*  Itevite  Med.  de  la  Suisse  JRomande,  June  20tli,  1889. 


TEBATOMATA. 


369 


posterior  aspect  of  the  sacrum  there  was  an  irregular  lobulated 
mass,  from  which  an  ill-shaped  limb  projected,  the  foot  being 
in  the  position  known  as  talipes  equino-varus.  At  the  lower 
part  of  the  tumour  there  was  a  depression  indicating  an 
imperforate  ano-genital  orifice. 

The  third  variety  is  illustrated  by  the  celebrated  Jean 
Battiste  dos  Santos  of  Portusfal.  The  chief  features  of  this 
case  were  Avell  described  in  1846  by  W.  Acton,*  and  nineteen 


Fig.  ISS.— Posterior  view  of  J.  B.  dos  Santos  at  tlie  age  of  six  months.     {After  Acton.) 

years  later  by  Ernest  Hartf  in  London,  and  by  HandysideJ  in 
Edinburgh.  The  chief  features  of  the  case  are  shown  in 
Fig.  188.  The  child  has  a  median  unpaired  limb  projecting 
from  the  pubes  and  situated  between  the  normal  limbs ;  its 
extremity  has  nine  separate  digits,  but  the  middle  one 
consists  of  two  coalesced  big  toes.  On  that  part  of  the  limb 
which  corresponds  to  the  buttock  there  is  a  dimple  represent- 
ing the  imperforate  anus  of  the  parasite ;  and  there  are 
two  penes. 

Reduplication   of  the   pelvic  limbs  occurs  frequently  in 

*  Med-Chir.  Trans.,  vol.  xxix.,  p.  103. 

f  lancet,  1865,  vol.  ii.,  p.  124. 

X  Ed.  Med.  and  Surg.  Journal,  18G6,  vol.  xi.,  part  ii.,  p.  833. 


370 


TERATOMA  TA. 


sheep,  calves,  and  birds,  and  has  been  especially  studied  by 
Cleland. 

Anterior  Dichotomy. — Cleavage  may  affect  the  facial 
portion  only  and  produce  reduplication  of  the  jaws,  or  it 
may  involve  the  head  and  produce  a  two-headed  individual. 
Should  it  extend  to  the  thoracic  region  of  the  spine,  then  an 
animal  with  two  heads  and  reduplicated  fore  limbs  is  the 
result.  When  partial  dichotomy  attacks  the  head  the  median 
parts  of  the  reduplicated  face  are  so  conjoined  and  malformed 
that  they  are  sometimes  found  hanging 
in  the  pharynx,  being  attached  to  its  roof 
by  a  pedicle.  Such  tumours,  called 
basicranial  teratomata,"^  are  very  apt 
to  be  confounded  with  pharyngeal  and 
palatine  dermoids.     (See  page  298.) 

Examples  of  dichotomy  involving  the 
whole  length  of  the  cranial  axis  are  by 
no  means  infrecjuent,  but  they  occur 
more  frequently  in  some  groups  of 
animals  than  in  others.  Many  examples 
have  been  recorded  in  foals,  in  calves,  and 
especially  in  snakes.     (Fig.  189.) 

Among  the  cases  illustrating  redupli- 
cation of  the  body  as  far  backwards  as  the 
umbilicus  the  best  known  is  the  celebrated 
Ritta-Christina,  born  at  Sassari,  in  Sardinia,  1829.  After 
surviving  her  birth  eight  months  and  a  half  she  died  in  Paris. 
Isidore  Geoffrey  Saint-Hilairef  gives  an  interesting  account  of 
the  anatomy  and  physiology  of  this  remarkable  girl. 

Harris^  has  carefully  described  a  similar  case  known  as 
the  blended  Tocci  brothers.  In  these  cases  the  adjacent 
upper  limbs  were  quite  distinct  and  well  formed,  but  in  some 
similar  cases  the  limbs  have  coalesced,  forming  a  median 
limb. 

Thus  far  we  have  been  concerned  with  reduplicated 
parts  that  reach  such  a  standard  of  development  that  their 
identification  is  neither  a  matter  of  difiiculty  or  doubt.    It  will 

*  For  some  examples,  cf.  Trans.  Odont.  Soc.  of  Great  Britain,  vol.  xxi.,  27. 
■j-  L'Anomalies  de  V Organisation,  tome  iii.,  ^.  119. 
J  American  Journal  of  Obstetrics,  a'oI.  xxv.,  460. 


Fig.  ISO  — Cephalic  e\tie- 
mity  of  a  two-lieaded 
suake. 


TEBATOMATA. 


371 


now  be  necessary  to  consider  the  meaning  of  those  attached 
parts  named  parasitic  foetuses,  and  the  shapeless  masses  to 
which  the  term  teratomata  in  all  strictness  applies.  This 
involves  the  consideration  of  the  condition  termed  acardiacus. 
It  happens,  and  not  infrequently,  that  in  cases  of  twins 


190. — Acardiac  foetus.    {Museum,  Middlesex  Hospital.) 


one  of  the  foetuses  is  of  natural  shape  and  proportions  and 
viable,  but  its  companion  is  very  imperfectly  developed,  and 
as  it  lacks  a  heart  (or  if  this  organ  be  present  it  is  rudimentary 
and  functionless)  is  said  to  be  acardiac.  The  degree  of 
development  varies  greatly. 


372 


TERATOMATA. 


A  common  example  is  sketched  in  Fig.  190.  The  head  and 
neck  are  absent,  the  upper  limbs  are  exceedingly  rudimentary, 
and  there  is  a  hernia-like  protrusion  of  viscera  at  the  umbilicus. 
This  specimen  had  no  heart,  lungs,  or  liver ;  but  intestines, 
kidneys,  and  female  genital  organs  were  present. 

In  rarer  cases  the  foetus  may  be  merely  represented  by  an 
irregular-shaped  mass  consisting  of  oedematous  integument 
surrounding  a  portion  of  the  skeleton,  usually  an  innominate 
bone  with  some  of  the  bony  elements  of  a  lower  limb. 

In    some    specimens   no   particular    skeletal    element   is 


Tubercle  mark- 
ing the  eud  of 
the  rudimentary 
spinal  cord. 


Fi".  191.— Acardiac  i'cetus. 


recognisable,  but  a  portion  of  intestine  or  rudiments  of  the 
genito-urinary  organs  can  be  detected.  To  such  examples  of 
acardiacus  the  adjective  amorphous  is  applied,  and  to  French 
Teratologists  they  are  known  as  "  anidian  monsters."  An 
acardiac  such  as  Fig.  191  has  been  described  as  a  dermoid 
of  the  umbilical  cord.*     (*S'ee  also  Fig.  192.) 

Between  the  two  forms  represented  in  Figs.  190  and  191 
every  variety  is  met  with,  and  in  cases  which  admit  of  the 
determination  of  the  sex  this  is  invariably  the  same  as  that  of 
the  well- developed  twin.  It  is  also  important  to  bear  in  mind 
that  acardiacs  can  only  occur  in  plural  births. 

Acardiacs   are   not   necessarily    separate    from   the   well- 

*  Budin,  Frogrl's  Medicale,  Dec.  31,  1887. 


TER.ATOMATA. 


373 


developed  twin,  but  may  be  attached  to  it  in  a  variety  of  ways. 
Many  such  examples  have  been  placed  on  record,  and  in  a 
few  the  autosite  and  acardiac  parasite  have  lived  and  attained 
maturity. 

One  of  the  best  examples  of  this  was  the  Indian  lad  Laloo. 
He  was  born  at  Oovon  in  Oudh,  and  at  the  age  of  seventeen 
years  was  brought  to  London.     This  boy  was  exhibited  at  the 


Cervical  vertebra.  ,  ,, 

Centrum  of  vertebra.  . ^. 5l 

Spinal  cord 


Fig.  192.— Acardiac  in  Fig.  191  shown  in  section. 


Pathological  Society  in  1888,  and  in  the  Transactions  for  that 
year  there  is  a  detailed  report  of  the  lad  drawn  up  by  Mr. 
S.  G.  Shattock  and  myself.  The  general  features  of  the  case 
are  shown  in  Fig.  182.  The  degree  of  development  of  the 
parasitic  foetus  is  similar  to  the  variety  of  acardiacus  showm 
in  Fig.  190.  It  has  arms  and  legs,  a  pelvis,  urinary  organs, 
and  a  well-formed  penis.  The  parasite  is  attached  to  the 
thorax  of  the  autosite  by  a  bony  pedicle  near  the  xyphoid, 
but  somewhat  to  the  right  of  the  middle  line;  its  anus  is 
imperforate  and  indicated  by  a  shining  linear  scar. 

It  is  an  interesting  fact  that  individuals  such  as  Dos  Santos 
are  capable  of  begetting  children,  and  the  offspring  do  not 
share  the  deformity  of  the  father.  This  also  holds  good  for 
females  with  parasitic  foetuses.  The  woman  represented  in 
Fig.  186  had  brought  forth  several  well-formed  children. 


374 


TEBATOMATA. 


The  explanation  of  acardiac  foetuses,  whether  free  or 
parasitic,  seems  to  be  this : — Two  embryos  arise  from  a  single 
ovum  ;  in  some  instances  the  cleavage  is  complete,  but  the 
heart  of  one  embryo  is  defective.  The  circulation  of  the  two 
embryos  is  continuous  at  the  placenta,  and  the  heart  of  the 
normal  embryo  is  able  to  maintain,  in  a  measure,  the  blood - 
current  in  its  companion,  and  thus  save  it  from  complete 
suppression.  Sir  Astley  Cooper*  demonstrated  this  com- 
pensatory mechanism  in  the  case  of  an  acardiacus  placed  in 
his  hands  by  Dr.  Hodgkin.     An  inspection  of  the  drawing  of 


Fig.  193. — Young  toad  with  a  supernumerarj'  hind  limb. 
(Museum,  University  College,  London.) 

the  placenta  from  this  case  (Plate  VII.)  shows  that  the 
umbilical  vessels  in  the  two  sections  of  the  compound 
placenta  were  directly  continuous. 

In  the  case  of  a  parasitic  acardiac — e.g.,  Laloo — the  circula- 
tion must  be  directly  inaintained  by  the  heart  of  the  autosite, 
as  an  independent  heart  has  not,  so  far  as  I  am  aware,  been 
detected  in  the  parasite.  The  blood  current  is  always  ex- 
tremely slow  in  the  acardiac,  and  thermometric  observations 
demonstrate  that  its  temperature  is  several  degrees  lower 
than  that  of  the  autosite. 

Thus  a  study  of  the  circumstances  surrounding  the 
development  of  twins  and  duplex  monsters  brings  us  to  the 
conclusion  that  teratomata  may  arise  either  from  partial 
dichotomy  of  the  trunk  axis  of  the  embryo,  or  from  complete 
duichotomy.  In  the  latter  case,  while  one  twin  has  gone  on  to 
full  development  the  growth  of  the  other  has  been  arrested, 

*  Guy's  Hospital  Eeports,  vol.  i.  218,  1836. 


Placenta  of  the 
Aeardiac. 


Artery 

and 
Vein  distributing  Blood 
to  the  Aeardiac. 


Umbilical  Cord  of 
Healthy  Twin. 


PLATE  VII.  — Placenta  from  a  Case  of  Twins,  one  of  which  was  an  Aeardiac. 

{Astley  Cooper.) 


TERATOMATA.  375 

and  in  some  cases  the  suppression  has  been  so  great  that  the 
companion  foetus  is  represented  by  a  deformed  or  shapeless 
mass  consisting  of  integument  covering  ill-formed  pieces  of  the 
skeleton  and  portions  of  viscera. 

In  a  few  cases  of  parasitic  fo3tuses  we  are  able  to  offer  a 
probable  opinion  as  to  whether  the  reduplicated  parts  are  due 
to  partial  dichotomy  of  the  trunk  or  are  the  result  of  complete 
cleavage,  in  which  one  of  the  foetuses  becomes  an  acardiac. 
In  very  many,  indeed  in  the  majority  of  teratomata,  it  is 
absolutely  impossible  to  decide  in  favour  of  one  method  or 
the  other. 

Treatment. — Parasitic  acardiacs  are  in  almost  all  cases  so 
extremely  valuable  as  sources  of  gain  in  fairs,  shows,  and  large 
cities  that  the  parents,  or  the  unscrupulous  individuals  who 
get  possession  of  these  children,  will  not  permit  operative 
interference.  When  the  parasitic  acardiac  is  of  the  amor- 
phous variety  (Fig.  191)  and  attached  to  the  dorsal  surface 
of  the  sacrum,  attempts  may  be  made  to  remove  them.  The 
children  rarely  survive  the  interference. 


>76 


CHAPTER    XLII. 
GROUP    IV. 

CYSTS. 

Cysts  or  Cystomata  result  from  the  abnormal  dilatation  of 
pre-existing  tubules  or  cavities.  In  the  simplest  forms  they 
consist  of  a  wall  usually  composed  of  fibrous  tissue,  but  it  is 
not  infrequently  mixed  with  muscle-tibre.  The  cyst-contents 
may  be  mucus,  bile,  saliva,  etc.,  according  to  the  nature  of 
the  organ  with  which  the  cyst  is  associated. 


Genera. 


Retention  cysts. 


II.  Tubulo-cysts. 


III.  Hydroceles. 


Species. 

Hydrometra. 

Hydrosalpinx. 

Hydronephrosis. 

Hydrocholecyst. 

Vitello-intestinal. 

Allantoic  (urachal). 

Paroophoritic. 

Parovarian. 

Cysts  of  Gartner's  duct. 

Cystic  disease  of  testis. 

Encysted  hydrocele  of  testis. 

Cysts  of  Mliller's  duct. 

Of  the  tunica  vaginalis. 


IV.  Gland  cysts. 


Of  the  canal  of  Nuck. 
Of  the  ovary. 
Of  the  neck. 
Ranulse. 

Pancreatic-cysts. 
Chyle-cysts. 
D  aery  ops. 
There    are   conditions   often  classed  as   cysts    which    are 
arranged  in  a  sub-group  entitled  Pseudo-cysts. 

I.  Diverticula.  Intestinal ;  Vesical ;  Pharyn- 

geal; OEsophageal;  Tracheal; 
Synovial ;  Meningeal. 
II.  Bursse.  Bursa. 


RETENTION   CYSTS.  377 

Genera.  Sjjecics. 

TTi.  Neural  cysts.  Hydrocephalus. 

Hydrocele  of  fourth  ventricle. 

Meningocele  (cranial). 

Spina  bifida. 
IV.  Parasites.  Hydatids. 

RETENTION   CYSTS, 

When  the  duct  of  a  gland  becomes  obstructed  the  fluid, 
hindered  from  escaping,  accumulates  in  the  ducts  and  acini 
and  dilates  them.  If  the  hindrance  to  the  free  flow  of  the 
secretion  is  maintained,  or  oft  repeated,  the  glandular  tissue 
becomes  impaired,  then  atrophies,  and  finally  the  gland  and 
its  duct  become  converted  into  a  fluid-containing  sac  or  cyst. 

It  is  generally  believed  that  when  the  duct  of  a  gland  is 
completely  obstructed  the  conversion  of  the  parts  into  a  cyst 
is  a  passive  process ;  but  occasion  will  be  taken  in  the  course 
of  this  section  to  show  that  this  is  not  the  case.  When  an 
excretory  duct  is  so  completely  obstructed  that  no  secretion 
escapes,  then  the  gland  rapidly  atrophies.  Retention  cysts  are 
due  to  obstruction  to  the  free  flow  of  secretion,  or  temporary 
arrests  of  the  flow  frequently  recurring.  The  best  example  of 
cysts  arising  in  this  way  are  those  due  to  dilatation  of  the 
pelvis  and  infundibula  of  the  kidney — a  condition  known  by 
the  term  hydronephrosis. 

The  purest  forms  of  retention  cysts  arise  in  connection 
with  hollow  organs,  the  inner  walls  of  which  are  provided  with 
glands.  The  vermiform  appendix  is  a  case  in  point.  This 
tubular  structure  is  richly  provided  with  glands.  (Fig.  194.) 
Occasionally  the  communication  of  the  appendix  with  the 
csecum  is  obstructed,  and  the  glands  continuing  to  secrete,  the 
accumulating  fluid  distends  the  appendix  into  a  sausage- 
shaped  cyst  and  sets  up  local  symptoms  of  great  severity. 

The  uterus  is  another  example.  After  a  difiicult  labour 
the  walls  of  the  cervical  canal  are  not  infrequently  damaged, 
and  in  the  process  of  repair,  the  canal  may  become  obstructed. 
This  leads  to  retention  of  the  products  secreted  by  the  uterine 
glands,  and  the  uterus  will  attain  such  proportions  as  to  cause 
the  enlargement  to  be  attributed  to  pregnancy  ;  the  condition 
is  known  as  hydrometra.  It  is  occasionally  seen  in  women, 
but  is  more  common  in  mammals  normally  furnished  with 


378 


CYSTS. 


bicorniiate  uteri,  siicli  as  ewes,  cows,  mares,  and  soavs.  It  may 
be  unilateral  or  bilateral.  When  occurring  in  mannnals  in 
which  the  uterus  has  long  cornua — e.q.,  cat,  bitch,  hare,  etc. — 
the  distended  cornua  are  apt  to  be  confounded  with  Fallopian 
tubes.  It  may  affect  one  or  both  cornua  of  a  bihorned  uterus 
in  women. 

The  danger  of  retention  of  this  kind  is  not  so  much  due  to 
the  size  of  the  cyst  as  to  the  great  risk  that  ensues  when 


Fig.  ] 94. — Section  throiigli  the  tip  of  tlie  vermiform  appendix,  to  show  the  abundance  of  its 
glands.    A,  outer  coat ;  b,  adenoid  tissue  ;  c,  muscular  capsule  to  the  adenoid  tissue. 

large  collections  of  retained  secretions  are  invaded  by  putre- 
factive organisms.  The  cysts  in  such  an  event  become  con- 
verted into  abscesses  and  the  life  of  the  individual  is  greatly 
imperilled.  These  changes  in  retention  cysts  are  indicated 
by  special  names — as  pyometra,  pyonephrosis,  etc. 

HYDRONEPHROSIS. 

The  inode  of  origin  of  retention  cysts  may  be  studied  in 
the  kidneys.  The  secretion  from  these  glands  is  conducted 
into  the  bladder  by  means  of  two  ducts  35  cm.  (14  inches) 


RETENTION    CYSTS. 


379 


lonsf,  known  as  the  ureters 

o 


the  urine  is  discharged  from  the 
bladder  through  the  urethra.  If  from  any  cause  the  urine  is 
hindered  from  escaping  freely,  either  from  the  bladder  or  from 


Fig.  195. — Hydronephrosis  secondary  to  a  lai'ge  calculus  in  the  bladder;  two  fragments  of 
calculus  occupy  the  prostatic  portion  of  the  urethra.  The  left  kidney  was  in  a  similar 
condition.  The  patient,  a  man  twenty-six  years  of  age,  died  with  complete  suppression  of 
urine.    (Museum,  Middlesex  Hospital.)     [J  nat.  sizc.^ 

the  ureters  into  the  bladder,  it  accumulates  in  the  ureters  and 
dilates  them ;  the  pressure  then  acts  upon  the  pelvis  of  the 
kidney,  and  if  maintained  causes  the  renal  pelvis  to  be  dilated 
into  a  large  sac,  converts  the  infundibula  into  large  tubes,  and 
finally  induces  atrojDhy  of  the  renal  tissue  until  the  kidney  is 


380 


CYSTS. 


converted  into  a  multilocular  sac.    To  a  kidney  thus  converted 
the  term  hydronephrosis  is  applied.     (Fig.  195.) 

Hydronephrosis  arises  from  a  variety  of  causes.  It  must 
be  borne  in  mind  that  when  the  obstruction  is  complete  and 
persists,  the  kidney  very  rapidly  atrophies.  Large  examples 
of  hydronephrosis  are  produced  by  partial  obstruction  to  the 


Fig.  ]96. — Bilateral  hydronephrosis  in  a  new-boru  child.     {Museum,  Middlesex  Hospital.) 


flow    of  urine,    or   frequently   recurring  attacks  of  complete 

obstruction. 

Hydronephrosis  may  be  bilateral  or  unilateral.    When  the 

obstruction  is  at  the  neck  of  the  bladder  or  in  the  urethra,  it 

will  be  bilateral. 

The  chief  causes  of  bilateral  hydronephrosis  are — 
Impacted  calculus  in  the  urethra,  or  near  the  neck  of  the 


RETENTION    CYSTS.  381 

bladder  (Fig.  197)  and  urethral  stricture.  Tumours  of  the 
prostate  gland,  especially  pedunculated  adenomata  (Fig.  115), 
or  pressure  upon  the  urethra  by  an  impacted  uterine  myoma. 
Bilateral  hydronephrosis  may  also  arise  from  pressure  on 
both  ureters — e.g.,  by  a  hydatid  cyst  of  the  pelvis,  by  a  large 
uterine  myoma,  or  other  variety  of  pelvic  tumour  (page  173). 
The  condition  is  occasionally  congenital,  and  the  most  careful 
examination  fails  to  detect  a  cause.     (Fig.  196.) 

Unilateral  hydronephrosis  has  many  causes  : — The  reten- 
tion of  a  calculus  in  the  vesical  segment  of  the  ureter  ;  tumour 
(villous)  of  the  bladder  situated  near  or  at  the  vesical  orifice 
of  the  ureter;  calculus  lodged  in  the  pelvis  of  the  kidney; 
papilloma  of  the  renal  pelvis ;  axial  rotation  of  the  kidney 
leading  to  kinking  of  the  ureter;  tumours  involving  the 
ureter,  as  in  cancer  of  the  uterus ;  or  pressing  upon  it  from 
without,  as  myomata  of  the  uterus;  ovarian  cysts  and 
tumours  of  the  pelvic  bones. 

In  double  hydronephrosis  secondary  to  obstruction  at  the 
neck  of  the  bladder  an  interesting  change  may  sometimes  be 
observed  at  the  vesical  orifices  of  the  ureters.  Normally,  these 
openings  scarcely  admit  a  fine  probe,  but  under  the  con- 
ditions just  mentioned  will  assume  a  circular  form,  and  be  so 
large  as  readily  to  admit  the  tip  of  the  little  finger,  so 
that  fluid  injected  into  the  bladder  through  the  urethra 
will  enter  the  ureters  and  gain  the  dilated  pelvis  of  the 
kidney.  This  condition  is  particularly  apt  to  supervene  upon 
oft-repeatecl  attacks  of  retention  of  urine,  secondary  to 
pressure  on  the  urethra  exercised  by  a  myomatous  uterus 
lying  low  in  the  pelvis,  and  becoming  impacted  immediately 
before,  and  at  the  incidence  of  each  menstrual  period.  It  is  a 
curious  fact  that  some  of  the  largest  hydronephroses,  uni- 
lateral and  bilateral,  that  have  come  under  my  notice  have 
been  cases  in  which  it  was  impossible  to  assign  an  adequate 
cause.  (Fig.  198.)  The  most  remarkable  example  of  this  is 
the  celebrated  case  of  Mary  Nix,^  aged  twenty-three  years. 
She  died  at  Hampton-Poyle,  near  Oxford,  with  a  large 
hydronephrosis  containing  fluid  to  the  amount  of  thirty 
gallons,   wine   measure.      The    dissection   of    the    body  was 

*  Phil.  Trans.,  1747,  vol.  xliv.  p.  337. 


382 


CYSTS. 


made  by  Samuel  Glass,  with  "  some  learned  gentlemen  of  the 
university."     I  have  read  the  account  very  critically,  and  feel 


Fig.  197. — Calculus  impacted  in  the  urethra  of  a  gelding,  producing  wide  dilatation 
of  the  vesical  orifices  of  the  ureters  and  double  hydronephrosis. 

there  is  no  doubt  as  to  the  renal  origin  of  the  hydronephrosis. 
Nothing  was  found  to  account  for  it. 

Intermitting  Hydronephrosis. — When  a  hydronephrotic 
kidney  is  of  large  size  it  can  be  perceived  clinically  as  a 
definite  tumour.  It  occasionally  happens  that  patients  come 
under  observation  with  a  swelling  in  the  loin  which  can  be 


IIETENTION    GYSTS. 


383 


readily  perceived  at  one  examination  bat  not  at  another,  or  it 
obviously  diminishes  in  bulk  without  completely  vanishing. 
In  some  of  these  cases  the  patients  are  able  to  state  definitely 
that,  coincidently  with  the  diminution  in  the  volume  of  the 
tumour,  there  has  been  a  sudden  increase  in  the  quantity 
of  the  urine  voided.     The  urine  in  some  instances  has  been 


Fig.  198.— Unilateral  (intermitting)  liydrouephrosis.     The  ureter,  at  the  point  where  it  left 
the  renal  sinus,  had  a  diameter  of  8  cm.     {Mitseiim,  Middlesex  Hospital.) 

found  to  contain  traces  of  blood  and  mucus.     To  hydrone- 
phrosis of  this  kind  the  term  intermitting  is  apphed. 

It  must  be  borne  in  mind  that  there  may  be  difficulty  in 
some  cases  in  deciding  clinically  between  a  very  large 
hydronephrotic  cyst  and  an  ovarian  or  parovarian  cyst,  and 
it  is  well  established  that  cysts  of  the  ovary  and  parovarium 
sometimes  rupture,  and  the  fluid,  escaping  into  the  peritoneum, 
is  absorbed  into  the  circulation  and  rapidly  excreted  by  the 
kidnej^s.  Thus,  jirofuse  diuresis  folloiving  upon  the  sudden 
disappearance  or  diminution  of  an  abdominal  tiiviour  is  as 


384 


CYSTS. 


eharacteristic   of   ruyture   of  an   ovarian    cyst   as    of   an 
intermitting  renal  cyst. 

There  can  be  little  doubt  that  nearly  all  hydronephroses 
intermit,  but  the  term  intermitting  hydronephrosis  is  reserved 
for  those  examples  in  which  great  diminution,  and  in  some 


Oiifice  of  the 
ureter. 


Fig.  199.— Pyonephrosis  of  one  half  of  a  horse-shoe  kidney  (Museum,  Middlesex  Hospital). 

(H.  Morris.) 


instances    temporary    disappearance,  of    the   swelling   takes 
place. 

Exceptionally,  both  kidneys  when  hydronephrotic  may 
intermit  alternately.  Of  this  rare  form  I  have  had  one  case 
under   my   care  ;   as   the   diagnosis   was   somewhat  obscure, 


PLATE  VIII. — Right  Kidney  with  two  Ureters,  one  of  which  opens  into  the 
Bladder  at  the  vesical  orifice  of  the  Urethra ;  the  lower  half  of  the  Kidney 
drained  by  this  Ureter  is  converted  into  a  pyonephrosis.  The  upper  half 
drained    by  the  normal   Ureter  is  healthy.     The   left  Kidney  was  normal. 

{Miiseum,  Middlesex  Hospital.)    \  nat.  size. 


RETENTION  CYSTS.  SSS- 

the  tumours  were  explored  through  an  abdominal  incision. 
In  the  course  of  the  proceeding  the  phenomenon  of  inter- 
mission was  actually  observed.  The  hydronephrosis  diminished 
in  size,  and  the  bladder  slowly  filled. 

There  are  a  few  rare  varieties  of  renal  cysts  that  may  be 
mentioned,  such  as  hydronephrosis  of  one  half  of  a  horse-shoe 
kidney  (Fig.  199) ;  or  a  kidney  may  have  two  ureters,  one  of 
which,  with  the  portion  of  the  kidney  drained  by  it,  becomes 
dilated  and  sacculated,  the  other  half  of  the  kidney  remaining 
healthy.     (Plate  Yin.) 

When  putrefactive  organisms  gain  entrance  to  a  dilated 
renal  pelvis,  either  from  the  bladder  by  way  of  the  ureter,  or- 
from  the  colon  adjacent,  suppuration  ensues  and  the  cyst 
becomes  a  pyonephrosis. 

Hydrocholecysts. — The  gall  bladder  consists  of  three  coats 
of  which  the  middle  one  contains  unstriped  muscle  fibre  ;  the 
inner  one  is  mucous  membrane,  its  epithelium  being  directly 
continuous  with  that  lining  the  hepatic  ducts  on  the  one 
hand  and  with  the  epithelium  covering  the  duodenum  on  the 
other.  The  outer  coat  is  derived  from  the  peritoneum  and 
subserous  tissue.  Bile  from  the  hepatic  ducts  finds  its  way 
into  the  gall  bladder  by  way  of  the  cystic  duct,  and  when  it 
escapes  from  the  gall  bladder  it  again  traverses  the  cystic 
duct  and  passes  along  the  common  bile  duct  to  the  duodenum. 
The  common  duct  just  as  it  enters  the  wall  of  the  intestine 
receives  the  duct  of  the  pancreas.  The  point  of  junction  is 
indicated  by  a  slight  recess  known  as  the  diverticulum  of 
Vater.  The  peculiar  arrangement  of  the  ducts  leading  to  and 
from  the  gall  bladder  renders  it  peculiarly  liable  to  have  its 
communications  interfered  with.  Obstruction  may  occur  in 
the  cystic  duct,  in  the  common  duct,  in  the  diverticulum  of 
Vater,  or  in  the  wall  of  the  duodenum.  The  obstruction  may 
be  due  to  impacted  gall-stones,  a  pancreatic  concretion  in  the 
diverticulum,  tumours  of  the  pancreas,  duodenum,  etc. 

When  obstruction  in  the  common  duct  is  complete  and 
persistent,  the  gall  bladder  may  atrophy.  When  incomplete, 
or  if  complete  the  obstruction  be  only  temporary,  and  especially 
if  frequently  repeated,  the  gall  bladder  will  become  greatly 
distended.  When  the  cystic  duct  is  obstructed,  and  no  bile 
finds  its  way  into  the  gall  bladder,  the  latter  may  become 
z 


386  CYSTS. 

so  distended  with  mucoid  fluid,  and  attain  such  large  propor- 
tions as  to  be  mistaken  for  an  ovarian  cyst.  The  fluid  that 
accumulates  in  the  gall  bladder  under  these  conditions  is 
probably  the  result  of  cholecystitis;  such  a  distended  gall 
bladder  is  called  a  hydrocholecyts.  Sometimes  adhesions 
occur  between  the  dilated  gall  bladder  and  adjacent  intestine 
(duodenum  or  colon),  intestinal  fluids  gain  access  to  it,  and 
suppuration  ensues,  converting  it  into  a  pyocholecyst.  Some- 
times a  fistula  forms  between  the  intestine  and  the  cyst. 
Suppuration  may  occur  in  the  gall  bladder  in  consequence 
of  septic  organisms  finding  their  way  into  it  from  the  intestine 
along  the  ducts  of  the  gall  bladder. 

Treatment. — During  the  last  ten  years  very  great  advances 
have  been  made  in  the  surgical  treatment  of  cystic  tumours 
of  all  kinds,  and  the  principle  is  gaining  ground  that  when  it 
is  possible  to  remove  them  without  greatl}^  endangermg  life, 
this  radical  mode  of  treatment  gives  the  most  satisfactory 
results. 

This  is  well  borne  out  in  the  case  of  unilateral  hydro- 
nephrosis. When  the  surgeon  is  satisfied  that  an  individual 
has  a  large  sacculated  kidney,  and  the  fellow  gland  is  in  good 
condition  and  performing  its  functions  properly,  the  hydro- 
nephrotic  cyst  can  be  removed  through  an  incision  in  the 
loin  with  as  little  risk  as  attends  the  excision  of  simple  ovarian 
or  parovarian  cysts.  It  is  undesirable  in  a  work  of  this  kind 
to  enter  into  details  regarding  the  surgical  treatment  of  such 
cysts.  Certain  it  is  that  surgeons  were  formerly  content,  when 
they  considered  it  necessary  to  interfere  with  a  hydronephrotic 
cyst,  to  expose  the  cyst-wall  through  a  lumbar  incision,  incise 
it,  evacuate  the  contents  and,  by  stitching  the  cyst  to  the 
edges  of  the  skin-wound,  establish  a  fistula.  Henry  Morris, 
however,  has  demonstrated  that  the  best  method  of  dealing 
with  a  unilateral  hydronephrosis  is  to  remove  the  cyst 
completely  (nephrectomy),  and  this  excellent  practice  is 
becoming  universal  among  surgeons  and  is  as  successful  as 
ovariotomy. 

It  is  a  peculiar  circumstance  that  in  many  instances  a 
hydronephrosis  has  assumed  such  large  dimensions  as  to 
extend  into  the  false  pelvis  and  simulate  an  ovarian  tumour. 
In  many  instances  the  resemblance  has  been  so   close   that 


RETENTION  CYSTS.  387 

experienced  physicians  and  expert  surgeons  have  been  so 
deceived  that  operations  have  been  performed  as  for  ovario- 
tomy, mitil  the  abdomen  was  opened  and  the  error  discovered. 
In  such  a  case  the  surgeon  should  ascertain  if  the  companion 
kidney  is  health}^,  then  close  the  abdominal  incision  and 
remove  the  hydronephrosis  through  an  opening  in  the  loin. 
This  class  of  case  furnishes  admirable  results. 

The  surgical  treatment  of  dilated  gall  bladders  (hydro- 
cholecysts)  is  in  a  sort  of  transition  stage.  The  ideal  operation 
is  removal  of  the  gall  bladder  after  ligature  of  the  cystic  duct 
(cholecystectomy) :  but  there  are  many  diiEiiculties  to  surmount 
before  it  will  be  possible  to  carry  out  this  manoeuvre,  save  in 
exceptional  cases.  At  present  the  safest  jjractice  consists  in 
exposing  the  gall  bladder  through  an  incision  in  the  bell}^- 
wall,  evacuating  its  contents,  and  removing  the  blockade 
if  possible  ;  the  cyst  is  then  stitched  to  the  edges  of  the 
peritoneum  and  the  wound  allowed  to  close  by  granulation. 

The  Gruttural  Pouches  of  the  Horse. — lu  man  tlie  pharyngeal  orifice  of 
each  Eustachian  tube  opeus  in  relation  with  a  bay  or  recess  termed  the 
fossa  of  Roseumiiller.  In  the  horse  they  terminate  in  a  very  different 
manner.  When  the  head  is  removed  at  the  occipito-atlantal  articulation, 
and  the  pharynx,  with  the  associated  structures,  carefully  dissected  from 
the  muscles  on  the  ventral  asjiect  of  the  cervical  region  of  the  spine,  it 
will  be  found,  as  a  rule,  difficult  to  avoid  cutting  into  two  large  sacs 
separated  from  the  atlas  and  axis  by  loose  connective  tissue.  These  sacs 
reach  to  the  base  of  the  skull,  extend  downwards  to  the  lar}Tix,  and  send 
processes  to  occupy  the  intervals  between  the  long  styloid  processes  and  the 
mandible.  These  sacs  are  the  guttural  pouches ;  they  abut  upon,  but 
have  no  communication  with  each  other,  and  occupy  the  whole  of  the 
naso-pharynx.  Each  pouch  is  lined  with  delicate  mucous  membrane 
containing  glands  and  furnished  with  ciliated  epithelium. 

The  mucous  membrane  of  the  guttural  pouches  is  directly  continuous 
with  that  lining  the  Eustachian  tubes.  The  pouches  themselves  appear 
as  large  saccular  dilatations  of  the  terminal  ends  of  the  tubes,  and  for 
this  reason  they  are  termed  by  some  writers  the  Eustachian  pouches. 
Each  pouch  opens  into  the  pharynx  immediately  above  the  soft  palate  by 
a  vahailar  orifice  ;  one  side  of  the  valve  is  formed  by  the  leaf-like  termina- 
tion of  the  Eustachian  tube.  Of  the  functions  of  these  pouches  notliing 
is  known.  They  are  often  a  source  of  inconvenience  to  horses,  for  the 
mucous  membrane  is  very  prone  to  become  inflamed,  and  the  scanty  outlet 
for  the  secretion  leads  to  its  retention  and  the  consequent  dilatation  of 
the  sacs.  "When  enlai'ged  in  this  way  they  may  have  a  capacity  of  six  or 
more  ounces  each.     The  retained  secretion  may  decompose,  and  the  sac 


388 


CYSTS. 


become  distended  witli  pus,  wliicli  is  discharged  at  iiitei-vals  through  thfi 
nose ;  or  the  pharyngeal  orifice  may  be  occluded,  and  the  pouches ,  enlarge 
to  such  an  extent  as  to  require  an  incision  through  the  skin  of  the  neck, 
or  through  the  mouth. 

Not  infrequently  the  contents  of  the  pouches  become  inspissated  and 
formed  into  concretions.    These  are  of  different  shapes  and  sizes,  and  vaiy 


Fig.  200. — Concretions  fiom  tlie  g  ittunl  pouches  of  lioises      {Nat.  size.) 


in  number  from  one,  two,  or  three  to  fifty  or  even  more.  Generally  they 
are  of  an  oval  shape ;  not  infrequently  tliey  resemble  beans.  In  con- 
sistence these  concretions  are  like  cheese,  and  on  section  have  a  laminated 
appearance.  They  are  composed  of  mucus  and  inflammatory  products 
mixed  up  with  inorganic  particles.     (Fig.  200.) 

The  grit  in  these  concretions  enables  an  explanation  to  be  offered 
concerning  the  liability  of  the  pouches  to  attacks  of  inflammation.  As 
the  orifices  of  the  pouches  are  in  direct  communication  with  the  nasal 
passages,  dust  can  easily  gain  entrance  into  them  when  snuffed  up  with 
fragments  of  hay,  straw,  dried  seeds,  and  other  organic  and  inorganic 
particles  from  dusty  nose-bags  and  mangers. 


389 


CHAPTER    XLIIL 


TUBULO-CYSTS. 

The  human  body,  in  common  with  that  of  many  mammals, 
contains  a  certain  number  of  tubes  which,  so  far  as  is  known, 
serve  no  useful  jD^^i'P^se  in  the  adult,  and  may  be  called  in 
consequence  functionless  ducts. 
Some  of  these — e.g.,  the  vitello- 
intestinal  duct  and  the  urachus 
— were  probably  useful  to  the 
embryo ;  others,  like  the  paro- 
varium and  Gartner's  duct,  are 
serviceable  in  the  male,  as  they 
act  as  conduits  to  the  testis. 
Functionless  ducts  must  not 
be  confounded  with  obsolete 
canals :  these  serve  no  useful 
purpose  in  man,  but  were,  in  all 
probability,  functional  in  the 
ancestors  of  existing  vertebrata 
(page  308).  Both  sets  of  canals 
are  of  interest  to  the  patholo- 
gist, as  they  are  the  source 
of  cysts  which  are  not  only 
inconvenient  to  the  individual, 
but  actually  dangerous  to 
life. 

The  genus  Tubulo-Oysts  in- 
cludes the  seven  following  species : — (1)  Cysts  of  the  vitello- 
intestinal  duct ;  (2)  Allantoic  (urachus)  cysts  ;  (3)  Paroopho- 
ritic cysts  ;  (4)  Parovarian  cysts  ;  (5)  Cystic  disease  (adenoma) 
of  the  testis ;  (6)  Cysts  of  Gartner's  duct ;  and  (7)  Cysts  of 
Mtiller's  duct. 

Cysts  of  the  Vitello-Intestinal  Duct. — It  is  not  uncommon 
to  find  connected  with  the  umbilicus  of  babes  and  young 
children  small  tumours  varying  in  size  from  a  pea  to  a  cherry. 
These  tumours  are  of  a  bright  red  colour,  soft  and  velvety  to 
the   touch,  and  are,  as  a  rule,  connected   to   the   navel    by 


Fig.  201. — Congenital  pedunculated  tumour 
of  the  navel. 


390 


CYSTS. 


Lung  diverticului 


Stomacli. 


slender  pedicles,  and  in  appearance  resemble  red  currants ; 
occasionally  they  are  sessile.     (Fig.  201.) 

These  tumours  are  composed  of  unstriped  muscle  fibre, 
mucous  membrane,  Lieberkiihn's  follicles,  and  columnar  epi- 
thelium collected  into  a  mass. 
Typical  cases  have  been  care- 
fully described  by  Kolaczek,* 
Colmanf,  and  others. 

In  rarer  cases  the  umbi- 
licus is  occupied  by  a  cyst, 
which  may  project  externally 
or  internally.  Such  a  cyst  is 
lined  with  mucous  membrane 
furnished  with  villi,  columnar 
epithelium  and  follicles.  A 
cyst  of  this  character  is  easily 
confounded  with  the  sac  of  an 
umbilical  hernia. 

RoserJ  reported  a  case  in 
which  a  young  man  came 
under  his  care  with  a  sinus 
at  the  umbilicus  from  which 
a  slimy  discharge  issued. 
Some  time  before,  a  surgeon 
had  removed  a  small  cyst 
which  projected  from  the  navel,  but  the  wound  never 
healed.  The  discharge  from  the  sinus  frequently  corroded  the 
surrounding  skin.  On  introducing  a  probe,  the  sinus  was 
found  to  lead  into  a  cavity  measuring  six  centimetres  in 
diameter.  The  C3^st  was  removed,  and  microscopical  examina- 
tion showed  it  to  present  all  the  histological  characters  of 
intestine. 

Zumwinkel§  has  described  the  case  of  a  girl  seven  years  of 
aofe  who  had  a  small  fistula  on  the  left  side  of  the  navel  from 
which  slimy  fluid  issued.  The  skin  surrounding  the  fistula 
was  ulcerated.     A  probe  introduced  into  the  opening  entered 

*  Langenbeck's  "Archiv,"  bd.  xviii.,  s.  349. 
f  Trans.  Path.  Soc,  vol.  xxxix.,  p.  110. 
X  Langenbeck's  "  Archiv,"  bd.  xx.,  s.  472. 
§  Langenbeck's  "Archiv,"  bd.  xl.,  s.  838. 


Vitello-intestinal 
duct. 


Fig.  202.— Diagi-am  of  the  alimentary  canal 
of  the  embryo,  showing  the  position  of  the 
yollv  sac. 


TUBULO-GYSTS.  391 

to  the  depth  of  1  cm.  The  parts  were  explored  through  an 
incision,  and  a  cyst  the  size  of  a  cheriy  exposed  and  removed. 
The  cyst  exhibited  the  histological  features  of  small  intestine. 

The  structure  and  position  of  pedunculated  tumours 
and  sessile  cysts  at  the  navel  indicate  the  structure  from 
which  they  arise — viz.,  a  remnant  of  the  vitello-intestinal  duct 
which,  in  the  embryo,  traverses  this  part  of  the  abdominal 
wall  (Fig.  202).  In  transverse  sections  of  the  umbilical  cord, 
close  to  the  belly- wall  of  the  embryo  at  the  fifth  month,  the 
vitello-intestinal  duct  can  often  be  detected,  with  its  lumen 
lined  with  sub-columnar  ejDithelium.  It  is  also  well  known 
that  the  duct,  instead  of  shrivelling,  sometimes  grows  j^ctri 
passu  with  the  gut  to  which  it  is  connected,  and  acquires  a 
lumen  almost  equal  to  that  of  the  ileum.  Instead  of  persisting 
from  the  gut  to  the  navel  the  duct  may  atrophy,  leaving  a 
small  portion  attached  to  the  intestine  or  to  the  abdominal 
wall.  Such  remnants  ma}^  develop  into  cysts  the  walls  of 
which  are  identical  in  structure  with  those  of  small  intestine. 

A  much  rarer  variety  of  cyst  arising  in  a  remnant  of  the 
vitello-intestinal  duct  is  due  to  the  distension  of  that  portion 
of  the  duct  which  is  connected  with  the  ileum.  In  recently 
hatched  chicks  the  intestinal  attachment  of  the  duct  is  often 
indicated  by  a  nipple-like  process  on  the  free  border  of  the 
gut.  This  is  hollow,  but  does  not  communicate  with  the 
lumen  of  the  ileum.  As  a  rule  it  atrophies  completely.  It 
may,  however,  grow  and  form  a  large  cyst.  In  Fig.  203  a 
piece  of  intestine  from  "an  emu  chick  is  shown  with  a  large 
cyst  suspended  from  it  by  means  of  a  narrow  and  acutely- 
torsioned  pedicle.  This  cyst  in  all  probability  originated  in  a 
persistent  portion  of  the  vitello-intestinal  duct. 

Cysts  of  like  proportions  and  of  identical  origin  have  been 
recorded  in  the  human  subject.  One  of  the  best-known  cases 
was  reported  by  Roth."^ 

Occasionally  a  persistent  vitello-intestinal  duct  will  remain 
open  at  the  umbilicus  and  discharge  faces.  Such  cases  have 
been  successfully  dealt  with  by  surgeons.f 

There  are  lew  structures  in  our  bodies  more  capable  of 
exciting  philosophical  speculation  than  the  yolk  sac  and  its 

*  Virchow's  "  Archiv,"  bd.  IxxxvL,  s.  371. 
f  Battle,  Trans.  Clin.  Soc,  vol.  xxvi. 


o 


892 


CYSTS: 


duct.  This  organ  may  in  man  and  all  the  higher  mammals 
be  regarded  as  vestigial,  for  its  duties  have  been  in  part  abro- 
gated by  the  allantois,  but  more  completely  by  the  placenta. 
In  the  human  embryo,  it  is  the  function  of  the  allantois  to 


Fig.  203. — Cyst,  probably  of  the  vitello-intestinal  duct,  attached  to  the  intestine  of  an  emu. 
(Museum,  Royal  College  of  Surgeons.) 


convey  the  blood-vessels  which  it  receives  from  the  developing 
aorta  and  distribute  them  to  those  chorionic  villi  destined  to 
form  the  fcetal  portion  of  the  placenta. 

In  some  sharks  the  yolk  sac  is  covered  with  vascular 
villous  tufts  which  fit  into  depressions  of  the  oviduct.  Even  in 
some  mammals — e.g.,  guinea-pigs^ the  yolk  sac  enters  into 
vascular  connection  with  the  uterine  mucous  membrane. 
There  are  abundant  and  good  reasons  for  Balfour's  conclusions 


TUB.ULO-CYSTS. 


393 


that  placental  mammals  are  descendants  of  forms  the  embryos 
of  which  had  large  yolk  sacs ;  but  the  yolk  became  reduced  m 
quantity  owing  to  the  nutriment  the  embryo  received  from 
the  maternal  tissues  by  means  of  the  vascular  connection  of 
the  yolk  sac  with  the  uterine  wall.  Subsequentl}'-  the  function 
of  the  yolk  sac  became  limited  by  the  allantois  and  the 
gradual  evolution  of  the  placenta,  and  finally,  so  far  as  man  is 
.concerned,  abolished.  Thus  in 
.man  it  is  vestigial,  and  like  such 
structures  in  general,  is  liable  to 
many  vagaries. 

There  is  good  reason  to  be- 
lieve that  the  vitello-intestinal 
duct,  besides  being  a  source  of 
.cysts,  is  also  responsible  for  the 
.curious  defect  in  the  ileum  to 
which  I  have  applied  the  name 
imperforate  ileum.  It  occa- 
sionally happens  that  the  lumen 
of  the  ileum  is  interrupted  b}^  a 
.perforated  diaphragm  (Fig.  204). 
To  such  a  condition  the  term 
septate  ileum  is .  applicable. 
When  such  a  diaphragm  is  pre- 
sent its  situation  is  sometimes 
indicated  by  a  marked  con- 
.striction  of  the  gut.  In  other 
specimens  a  more  or  less  perfect  valve  of  this  kind  is  associated 
with  a  persistent  duct  (Fig.  205).  In  such  cases  the  duct  opens 
into  the  ileum  on  the  distal  side  of  the  valve.  In  other  instances 
the  ileum  becomes  greatly  dilated  near  its  middle,  and 
the  walls  are  much  hypertrophied ;  to  this  succeeds  a  narrow 
isthmus  which  opens  into  a  normal  segment  of  ileum.  Lastly, 
in  the  complete  form  the  ileum  is  interrupted  as  in  Fig.  206. 

These  curious  defects  are  attributable  to  the  influence 
of  the  vitello-intestinal  duct  because  they  always  occur  in 
that  portion  of  the  ileum  to  which  the  duct,  when  per- 
sistent, is  attached— that  is,  they  do  not  occur  within  30  cm. 
of  the  ileo-csecal  valve,  and  are  rarely  found  at  a  greater 
distance  than  1  m.  from  the  csecum. 


Fig.  204. — Septate  ileum. 
(Mttseum,   Middlesex  Hos%)iUd.) 


394 


CYSTS. 


The  most  reliable  evidence  for  associating  these  defects 
with  the  duct  of  the  yolk  sac  is  that  furnished  by  Fig.  205, 
in  which  a  persistent  duct  and  a  valve  co-exist.  In  rny  early 
observations  I  had  regarded  imperforate  ileum  as  depending 

upon  the  influence  of  the 
vitello- intestinal  duct,  and 
subsequent  observations  put 
the  speculation  on  a  sound 
basis.*  The  specimens  which 
demonstrate  these  views  are 
preserved  in  the  museum  of 
the  Middlesex  Hospital. 

An  imperforate  ileum  is, 
of  course,  incompatible  with 
life,  but  an  individual  with  a 
septate  ileum  may  attain 
ad  ult  life.  The  consideration 
of  imperforate  ileum  has  been 
introduced  here  because  it 
throws  a  large  amount  of 
side  -  light  on  pharyngeal 
diverticula  and  imperforate 
pharynx. 

Treatment.  —  The  small 
pedunculated  cysts  and  polypi 
of  the  umbilicus  only  require 
the  application  of  a  thread 
or  silk  ligature  to  the  pedicle  and  a  snip  with  a  pair  of  scissors. 
Sessile  cysts  require  to  be  dissected  out.  The  grosser  mal- 
formations, such  as  imperforate  and  septate  ileum,  have  in  a 
few  instances  been  submitted  to  surgical  treatment,  but  the 
efforts  have  not  been  successful. 

Allantoic  (Urachus)  Cysts. — The  urinary  bladder  of  man 
in  common  with  that  of  mammals  generally  presents  at  its 
apex  an  impervious  cord  that  passes  to  the  umbilicus.  This 
cord  is  known  as  the  urachus.  At  birth  the  urachus  is 
usually  traversed  by  a  narrow  canal  lined  with  ej)ithelium 
directly  continuous  with  that  lining  the  bladder. 


Fig.  205. — Ileum  witli  a  persistent  vitello-intes- 

tinal  duct  associated  mtli  a  valve. 

[Museum,  Middlesex  Hospital.) 


*  British  Jledical  Journal,  1891,  vol.  i.,  p.  342. 


TUBULO-CYSTS.  395 

The  urinary  bladder  with  the  iirachus  is  the  persistent 
portion  of  the  allantois,  the  organ  which  in  the  early  embryo 
conveys  blood-vessels  from  the  aorta  to  the  developing 
placenta.  In  the  adult  the  urachus  hes  in  the  subperitoneal 
tissue  exactly  in  the  middle  line  of  the  anterior  abdominal 
wall,  between  the  summit  of  the  bladder  and  the  umbilicus. 
When  the  urachus  becomes  dilated  it  forms  a  cyst  lying 
outside  the  peritoneum  and  in  close  relation  with  the  bladder. 


Proximal  of   ileum 
sesmeut. 


Free  edge  of  mesentery, 


^       Distal  segment  of  ileum. 


^-i;| 


Fig.  206.— Imperforate  ileum.    {Museum,  Middlesex  Hospital.) 

Instead  of  a  portion  of  the  allantois  narrowing  to  form  a 
urachus,  the  whole  of  its  intra-abdominal  portion  may  dilate 
and  form  a  large  urinary  bladder.  Shattock*  has  carefully 
described  an  example  of  this. 

Several  cases  are  known  in  which  the  umbilical  end  of  the 
urachus  has  remained  patent  so  that  urine  was  voided  at  this 
spot.  A  urinary  calculus  has  been  extracted  from  such  a 
persistent  urachus.t 

Allantoic  cysts  arise  from  dilatation  of  a  urachus  which  is 

*  Trans.  Path.  Soc,  vol.  xxxix.,  p.  185. 

t  Thomas  Paget,  Med.-Chir.  Trans.,  vol.  xxxiii.,  p.  293,  and  vol.  xliv.,  p.  13. 


396  CYSTS. 

occluded  at  the  umbilicus  and  at  the  sumuiit  of  the  bladder. 
Such  cysts  are  usually  of  the  size  of  a  ripe  cherry.  Sometiiries 
iseveral  very  small  dilatations  are  formed,  causing  the  urachus 
•to  assume  a  moniliform  appearance. 

In  rarer -cases  the  urachus  may  dilate  into  a  cyst  as  large 
as  a  distended  bladder.  The  structure  of  these  large  cysts  is 
identical  with  that  of  the  bladder,  and  consists  of  unstriped 
muscle  fibre,  lined  on  the  inner  side  with  epithelium  similar 
to  that  covering  the  vesical  mucous  membrane.  In  some  of 
the  specimens  phosphates  are  deposited  on  the  cyst-wall.  In 
large  cysts  there  is,  as  a  rule,  a  communication  with  the 
bladder,  and  the  cyst  contains  urine.  A  urachus  cyst  must 
not  be  confounded  with  a  sacculus  at  the  apex  of  the  bladder 
extending  into  the  suspensory  ligament. 

Lawson  Tait*  has  published  details  of  allantoic  (urachus) 
cysts  that  have  attained  large  dimensions  ;  in  one  case  the 
cyst  had  a  capacity  of  ten  pints.  These  cysts  were  situated 
between  the  peritoneum  and  the  anterior  abdominal  wall. 

.    Allantoic  cysts  have  been  observed  in  many  mammals, 
such  as  the  pig,  horse,  ox,  mole,  etc. 

Treatment. — In  a  few  instances  large  allantoic  cysts  have 
been  removed  and  some  of  the  patients  have  survived.  At 
present  so  little  is  known  about  the  cysts  that  it  is  impossible 
to  decide  as  to  the  best  method  of  dealincr  with  them. 

o 

*  The  Brit.    Gyn.    Journal,    vol.    ii.  •  328  ;     Wutz,    "  Ueber    Urachus    und 
Urachuscysten  "  ;  Virchow's  "Archiv,"  bd.  xcii.  387. 


397 

CHAPTER   XLIV. 
TUBULO-CYSTS  (concluded). 

CYSTIC     TUMOURS     ASSOCIATED     WITH     REMNANTS     OF     THE 
MESONEPHROS  (WOLFFIAN  BODY),   ITS   TUBULES   AND    DUCT. 

It  is  well  established  that  in  the  embryo  the  mesonephros  is 
closely  associated  with  three  organs,  the  testis,  ovary,  and 
kidney.  It  is  also  a  fact  that  in  at  least  two  situations — viz., 
in  the  ovary  and  in  the  testis — remnants  of  the  glandular 
elements  of  the  mesonephros  may  be  occasionally  met  with  in 
the  adult.  Many  of  the  tubules  of  the  mesonephros  and  its 
duct  function  in  the  male  as  excretory  ducts  for  the  testis, 
but  in  the  female  they  persist  in  a  vestigial  condition,  as  the 
parovarium  and  Gartner's  duct. 

There  is  abundant  evidence  for  the  belief  that  many  cysts 
connected  with  the  testis,  ovary,  parovarium,  and  vagina 
arise  from  vestiges  of  the  mesonephros  and  its  excretory 
canals.  It  will  be  convenient  to  begin  the  description  of  these 
cystic  conditions  by  considering  those  which  arise  in  vestiges 
of  the  glandular  portion  of  the  mesonephros  in  the  female. 

Cysts  of  the  Paroophoron. — The  ovary  consists  of  two 
parts,  the  oophoi'on  and  the  paroophoron.  The  egg-bearing 
portion  is  the  oriphoron.  The  paroophoron  contains  no  ova, 
but  receives  the  tubules  of  the  parovarium.  (Fig.  207.)  It 
represents  the  remnants  of  the  mesonephros,  and  is  homo- 
logous with  the  paradidymis  of  the  testis.  In  the  adult 
ovary  the  paroophoron  consists  mainly  of  fibrous  tissue 
permeated  with  blood-vessels,  but  in  the  fcetus  and  youngs 
child  it  retains,  in  a  measure,  its  glandular  character. 

The  paroophoron  is  the  probable  source  of  cysts  that 
present  peculiar  characters.  In  the  early  stages  they  resemble 
parovarian  cysts  in  their  relation  to  the  mesosalpinx  and 
Fallopian  tube,  but  as  they  increase  in  size  they  burrow  deeply 
between  the  layers  of  the  broad  ligament,  and  make  their  way 
by  the  side  of  the  uterus,  travel  under  the  peritoneum,  and 
strip  it  from  the  floor  of  the  pelvis.  When  large,  these  cysts 
will  come  into  contact  with  the  common  iliac  veins  at  the  brim 
of  the  pelvis,  or  they  may  raise  up  the  anterior  layer  of  the 


398 


CYSTS. 


broad  ligament  so  as  to  invade  the  subserous  tract  of  the 
anterior  abdominal  wall. 

In  addition  to  their  burrowing  tendencies  these  cysts  are 
peculiar  in  that  their  inner  walls  are  papillomatous.  The 
number  of  warts  varies  in  different  cysts.  Some  have  only  a 
small  cluster ;  in  others  the  clumps  are  so  large  and  so 
numerous  that  the  cyst-wall  bursts  from  the  pressure 
exercised  by  them.  The  warts  are  usually  very  vascular, 
bleed  freely  when  handled,  and  are  frequently  calcified.  When 


Pig.  207. — Diagram  to  represent  the  cyst  regions  of  tlie  ovary,     a,  ooplioron  ;  b,  paro- 
ophoron ;  c,  parovarium ;  k,  Kobelt's  tubes  ;  g,  Gartner's  duct. 


a  papillomatous  cyst  ruptures,  the  cell-laden  fluid  it  contains 
is  dispersed  throughout  the  belly,  and  it  frequently  happens 
that  the  cells  become  engrafted  upon  the  peritoneum  and 
grow  into  warts.  In  such  cases  the  warts  are  usually  most 
numerous  on  the  peritoneum  in  the  recto-vaginal  pouch. 
Exceptionally,  the  cyst  will  rupture  into  the  connective  tissue 
of  the  broad  ligament,  and  warts  sometimes  spring  up  in  this 
tissue,  and  I  have  seen  them  clustering  around  the  urachus  as 
high  as  the  umbilicus.  Occasionally  the  warts  may  make 
their  way  through  the  cyst-wall  and  protrude  as  in  Fig.  208. 
Such  emancipated  warts  grow  luxuriously,  and  the  movements 
of  adjacent  coils  of  intestine  detach  the  surface  cells  and 
spread  them  about  the  belly.  It  frequently  happens  that 
surgeons  are  alarmed  when  they  find  warts  on  the  peritoneum, 
as  they  mistake  them  for  nodules  of  cancer  or  sarcoma.  There 


TUBUL0-CY8TS. 


399 


is,  however,  no  cause  for  alarm,  as  the  warts  quickly  disappear 
after  removal  of  the  primary  tumours.  In  this  respect  these 
warts  agree  with  those  which  grow  on  the  skin  (see  page  168). 
Skin  warts  often  appear  suddenly,  and  almost  as  suddenly 
disappear.  Thus  the  life  of  a  wart  is  often  very  transient. 
So  with  peritoneal  warts ;  but  as  long  as  the  seed  supply 
continues  new  warts  spring  up,  last  for  a  time  and  die,  to  be 


ifj Fallopian  tube. 


Parovarium. 
Ovarian  ligament. 


Fig.  208. — Ruptured  papillomatous  (paroophoritic)  cysts  of  the  ovary,    (i.) 


succeeded  in  their  turn  by  a  new  crop.  When  the  tumours 
are  removed  the  supply  of  germ  epithelium  ceases,  the  warts 
die,  and  the  crop  is  not  renewed. 

Paroophoritic  cysts  may  be  unilocular  or  multilocular ; 
some  attain  great  proportions,  but  the  infective  qualities  of 
the  cysts  are  in  no  way  influenced  by  their  size. 

These  cysts  are  rare  before  the  twenty-fifth  year.  The 
period  of  life  in  which  they  are  most  common  is  between  the 
twenty-fifth  and  fiftieth  years.  Coblenz*  was  probably  the 
first  to  distinguish  them  clearly  from  parovarian  cysts,  and  to 
associate  them  with  definite  structures.     His  observations  have 

*  Virchow's  "  Archiv,"  bd.  Ixxxiy.,  26. 


400  CYSTS. 

been  contirmed  by  Doran*  and  myself  t  by  investigations  on 
the  ovaries  of  fcjetuses  and  infants. 

Although  one  of  the  distinguishing  features  of  a 
paroophoritic  cyst  is  the  presence  of  papillomata,  it  must 
not  be  imagined  that  all  wart-containing  cysts  of,  or  near,  the 
ovary  arise  in  the  paroophoron.  Undoubted  parovarian  cysts 
sometimes  contain  warts,  and  there  is  a  species  of  cyst 
occasionally  met  with  in  the  mesosalpinx  in  relation  with  the 
tubo-ovarian  ligament  which  often  contains  warts.  Every 
projection  in  a  cyst  is  not  a  wart.  In  many  oophoritic  cysts 
the  microscope  has  shown  that  some  wart-like  structures  are 
clusters  of  glands. 

Parovarian  Cysts. — The  parovarium  consists  of  a  number 
of  narrow  tubules  situated  between  the  layers  of  the  mesosal- 
pinx. It  is  easily  seen,  when  the  mesosalpinx  is  stretched  and 
held  between  the  eye  and  a  light,  as  a  series  of  narrow  tubules 
radiating  from  the  ovary  to  join  a  longitudinal  tubule  situated 
at  a  right  angle  to  them.  In  form  and  disposition  these 
tubules  resemble  the  vasa  efferentia  of  the  testis.  The  par- 
ovarium and  the  vasa  efferentia  are  homologous  structures,  for 
they  are  the  persistent  tubules  of  the  mesonephros  (Wolffian 
body).  That  portion  of  the  ovary  into  which  they  dip,  the 
paroophoron,  is  derived  from  the  glandular  portion  of  the 
mesonephros. 

The  parovarium  in  its  typical  condition  consists  of  three 
parts: — (1)  An  outer  series,  free  at  one  extremity,  and  known 
as  Kobelt's  tubes.  (2)  An  inner  set  formed  of  about  twelve 
tubules  ;  these  are  often  referred  to  as  the  vertical  tubules. 
(3)  A  straight  tube  running  at  right  angles,  and  occasionally 
traceable  through  the  broad  ligament  to  the  vagina ;  this  is 
Gartner's  duct ;  it  is  homologous  with  the  vas  deferens  of  the 
male  (Fig.  207). 

The  cysts  that  arise  in  the  parovarium  are  of  two  kinds. 
Small  pedunculated  cysts  often  form  in  Kobelt's  tubes ; 
they  rarely  exceed  a  currant  in  size,  and  do  not  call  for 
comment,  as  they  are  of  no  clinical  importance.  These  cysts 
are  very  frequently  mistaken  for  the  hydatid  of  Morgagni, 
which,  when  present,  hangs  from  a  fimbria  of  the  tube.     The 

*  Trans.  Path.  Soc,  vol.  xxxii.,  147. 

t  Journal  of  Ajiatomy  and  Physiology,  vol.  xx.,  432. 


TUBULO-CYSTB.  401 

important  cysts  arise  from  the  vertical  tubules,  and  separate 
the  layers  of  the  mesosalpinx,  and  burrow  towards  the 
Fallopian  tube. 

When  small,  parovarian  cysts  are  transparent,  and  have 
very  thin  walls,  but  after  they  attain  the  size  of  a  cocoa-nut 
the  walls  become  thick,  and  the  mesosalpinx  in  relation  with 
the  cyst  becomes  thickened,  and  sometimes  the  muscle  fibre 
contained  in  this  part  of  the  broad  ligament  becomes  greatly 
increased.  Parovarian  cysts  sometimes  attain  a  great  size.  I 
removed  one  that  had  a  capacity  of  four  gallons  and  a  half 

Small  parovarian  cysts  are  lined  with  columnar  epithe- 
lium which  is  ciliated  in  some  specimens.  In  large  cysts 
it  becomes  stratified,  and  in  very  big  cysts  it  atrophies. 

The  fluid  in  small  cysts  is  limpid,  slightly  opalescent, 
sp.  gr.  1002 — 1007,  and  contains  a  substance  that  forms  a 
flocculent  precipitate  when  the  cyst  is  immersed  in  alcohol. 
In  large  cysts  the  fluid  is  usually  turbid  and  sometimes  con- 
tains cholesterine.  The  fluid  is  not  harmful,  for  when 
parovarian  cysts  rupture  into  the  peritoneal  cavity  the  fluid 
is  absorbed  and  excreted  by  the  kidneys.  After  rupture  the 
rent  will  heal  and  the  cyst  refill,  and  in  some  cases  the  cyst 
has  burst  and  refilled  many  times  without  causing  more  than 
temporary  inconvenience  to  the  patient. 

The  cyst  may  rotate  on  its  axis  and  twist  its  pedicle.  This 
movement  may  even  lead  to  complete  detachment  of  the  cyst. 
Exceptionally,  parovarian  cysts  suppurate.  Although  these 
cysts  occupy  the  mesosalpinx,  they  do  not  burrow  between  the 
layers  of  the  broad  ligament  below  the  ovarian  ligament,  but 
rise  up  out  of  the  pelvis.  This  accounts  in  a  large  measure  for 
the  safety  with  which  they  may  be  removed.  Parovarian 
cysts  are  almost  invariably  unilocular.  The  chief  features 
which  distinguish  a  parovarian  cyst  from  other  cysts  of  the 
broad  ligament  and  ovary  are  these  : — 

(1)  It  is  easily  shelled  out  from  the  mesosalpinx. 

(2)  The  ovary  may  often  be  found  attached  to  the  side  of 
the  cyst. 

(3)  The  Fallopian  tube  is  stretched  over  the  crown  of  the 
cyst,  but  never  communicates  with  it.     (Fig.  209.) 

Before  the  sixteenth  year  the  parovarium  appears  to  be 
quiescent,  but  on  the  advent  of  puberty  it  seems  to  become 


402 


CYSTS. 


stimulated.  A  considerable  proportion  of  cysts,  generically 
classed  as  ovarian,  removed  between  the  seventeenth  and 
twenty-fifth  years,  arise  in  the  parovarium.  There  is  no 
trustworthy  record  of  a  parovarian  cyst  being  observed  before 
the  sixteenth  year. 

Cysts  of  Gartner's  Duct. — It  has  already  been  mentioned 
in  the  description  of  the  parovarium  that  the  vertical  tubules 
of  this  structure  are  received  into  a  tube  running  at  right 
angles  to  them.  This  tube  when  persistent  throughout  its 
course  makes  its  way  between  the  layers  of  the  broad 
ligament  and  runs  downwards  on  the  uterus,  to  open  into  the 


Fig.  209. — Cyst  of  the  parovarium,  showing  its  relation  to  ovai-y  and  tube.    Two-thirds 
its  natural  size.        a,  oophoron  ;  b,  paroophoron  ;  r,  Fallopian  tube. 


vaofina  near  the  orifice  of  the  urethra.  This  tube  is  known  as 
Gartner's  duct,  and  is  the  duct  of  the  mesonephros  (Wolffian 
duct),  which  in  the  male  becomes  the  vas  deferens.  Gartner's 
ducts  rarely  persist  throughout  their  whole  extent  in  women. 
The  portion  that  receives  the  tubules  of  the  parovarium 
(Wolffian  tubules)  is  often  detected,  and  the  terminal  seg- 
ment, known  as  Skene's  tube,  may  be  occasionally  recognised 
in  the  vagina,  and  is  frequently  the  seat  of  a  trouble- 
some inflammation.  The  intermediate  segment,  as  a  rule, 
disappears.  In  the  sow,  and  especially  in  the  cow,  Gartner's 
ducts  often  persist  ;  in  the  cow  they  are  sometimes 
seen  as  large  as  crow-quills.  In  many  cows  they  become 
gradually  lost  on  the  sides  of  the  uterus,  but  in  some  cases 


TUBULO-CYSTS. 


403 


Gartner's  duct 


they  may  be  traced  easily  to  their  termination,  and  are  found 
to  open  in  the  vagina. 

The  interest  of  Gartner's  duct  to  the  pathologist  depends 
on  the  fact  that  the  terminal  segments  are  apt  to  become 
cyst-germs,  and  there  is  no  doubt  that  some  of  the  cysts  that 
occasionally  require  removal  from  the  vagina  arise  in  Gartner's 
ducts,  especiall}^  those  which 
are  lined  with  stratified  epi- 
thelium. Such  cysts  have 
been  known  to  attain  the 
size  of  a  fowl's  egg,  and 
are  usually  filled  with 
mucus. 

The  evidence  that  some 
species  of  vaginal  cysts  arise 
in  Gartner's  duct  is  not 
merely  circumstantial.  A 
specimen  that  came  under 
my  notice  in  a  cow  is  re- 
presented in  Fig.  210,  in 
which  the  vaginal  segment 
of  the  duct  expanded  to 
form  two  large  oval  dilata- 
tions, each  of  which  was 
large  enough  to  accommo- 
date a  hen's  egg.  The 
specimen  is  preserved  in  the 
museum  of  the  Royal  College 
of  Surgeons. 

In  the  male,  cystic  tumours  that  arise  in  the  vestiges 
or  remnants  of  the  mesonephros  (Wolffian  body)  and  its 
tubules  are  of  two  kinds  :  (1)  Encysted  hydrocele  of  the 
testicle,  and  (2)  general  cystic  disease  of  the  testicle. 

Encysted  Hydrocele  of  the  Testicle. — In  addition  to 
cysts  arising  in  connection  with  the  funicular  pouch  and  its 
sub-divisions  described  in  chap,  xlv.,  there  is  another  class 
termed  "  encysted  hydroceles  of  the  testicle." 

In  order  to  appreciate  the  nature  of  encysted  hydroceles  it 
will  be  necessary  to  consider  a  few  points  connected  with  the 
development  of  the  testicle.    This  gland  is  very  complex,  for  its 


Fig.  210.— Anterior  portion  of  a  cow's  vagina, 
showing  two  large  cysts  developed  in  the 
terminal  segment  of  Gartner's  duct. 


404 


CYSTS'. 


ducts,  the  vasa  efferentia,  epididymis,  and  vas  deferens,  were 
originally  the  excretory  ducts  of  the  mesonephros  (Wolffian 
body).  A  study  of  the  evolution  of  the  male  secretory  organ 
of  vertebrates  indicates  clearly  enough  that  the  ducts  have 
undergone  a  change  of  function,  and  their  relation  to  the 
testicle  is  secondary.  An  examination  of  the  embryonic  testis 
shows  that  remnants  of  the  mesonephros  persist  among  the 


Paiailidymis. 


Fig.  211.— Diagram  to  sliow  the  relation  of  the  mesonephros  and  its  ducts  to  the 
adult  testicle. 


ducts,  and  only  a  few  of  the  Wolffian  tubules  are  utilised  by 
the  testicle. 

The  relation  of  the  various  embryonic  structures  to  each 
other  is  shown  somewhat  diagrammatically  in  Fig.  211.  In  the 
adult  testis  it  will  be  readily  seen  that  a  few  of  the  Wolffian 
tubules  become  the  vasa  efferentia,  the  remainder  usually 
atrophy ;  but  in  many  individuals  one,  two,  or  more  persist, 
usually  as  pedunculated  cysts  of  small  size  at  the  top  of  the 
testicle. 

The  shrunken  remains  of  the  mesonephros  (Wolffian  body) 
sometimes  persist  as  a  collection  of  ctecal  tubes  furnished 
with  epithelium,  lying  among  the  vasa  efferentia,  between  the 
epididymis  and  the  testis,  and  often  extending  a  little  distance 
into  the  tissues  of  the  cord.  These  remnants  are  known  as 
the   paradidymis.     Thus   in   the   male   the   mesonephros    is 


TUBUL0-GY8TS. 


405- 


represented  by  the  paradidymis,  its  tubules  by  tlie  vasa 
efferentia  and  Kobelt's  tubes,  and  its  duct  by  the  epididymis, 
and  vas  deferens. 

The  cysts  to  which  the .  term  encysted  hydrocele  of  the 
testicle  should  be  applied  arise  sometimes  in  the  vasa  efferentia. 
of  the  testis  and  sometimes  in  Kobelt's  tubes,  and  it  is   a. 


Fig.  212.— Hydrocele  r)f  the  tunica  vaginalis,  ami  an  encysted  hydrocele  associated  ' 
with  the  same  testis.    {Museum,  Middlesex  Hospital.) 

curious  fact  that  these  cysts  arise  in  those  structures  which 
in  the  female  give  rise  to  parovarian  cysts.  As  encysted 
hydroceles  in  the  male  and  parovarian  cysts  in  the  female 
arise  in  homologous  organs,  these  cyst&  are  morphologically' 
homologous.  The  anatomical  characters  of  encysted  hydrocele' 
must  now  be  considered.  ' 

These  cysts  are  always  closely  associated  with  the  testis, 
but  lie  outside  its  tunica  vaginalis,  Jbut  they  may  project  into 


406  CYSTS. 

the  cavity  of  this  sac.  Occasionally  a  hydrocele  of  the 
tunica  vaginalis  is  associated  with  an  encysted  hydrocele. 
(Fig.  212.) 

When  an  encysted  hydrocele  is  very  large  it  may  so  over- 
lap the  testis  that  it  is  difficult  to  differentiate  between  it  and 
a  hydrocele  of  the  tunica  vaginalis,  until  actual  dissection  in 
the  course  of  an  operation  shows  that  the  cyst  is  independent 
of  the  tunica  vaginalis. 

The  lining  epithelium  of  these  cysts  may  be  of  the  stratified, 
cubical,  columnar,  or  even  of  the  ciliated  variety ;  they  contain 
fluid,  which  may  be  clear,  or  white  like  milk,  due  to  the 
presence  of  fat ;  sometimes  it  contains  spermatozoa.  It  may 
be  blood-stained.  In  size  these  cysts  vary  greatly.  As  a  rule, 
they  do  not  exceed  the  dimensions  of  an  egg,  and  often  are 
much  smaller ;  exceptionally,  one  of  them  may  exceed  a  fist 
in  size. 

An  encysted  hydrocele  must  not  he  confounded  with  a 
cyst  arising  in  an  unohliterated  funicular  ])rocess. 

In  addition  to  the  sessile  form  of  encysted  hydrocele  of 
the  testis,  there  is  a  pedunculated  variety  which  is  usually 
described  as  a  supernumerary  hydatid  of  Morgagni.  These 
cysts  rarely  exceed  a  cherry  in  size  and  arise  in  Kobelt's 
tubules.  As  a  rule,  only  one  cyst  is  present,  but  two  or 
three  are  not  uncommon.  Sometimes  they  will,  like  the 
hydatid  of  Morgagni,  project  into  the  cavity  of  the  tunica 
vaginalis. 

Our  knowledge  of  the  different  species  of  hydrocele  has 
become  more  definite  since  surgeons  have  followed  the 
practice  of  dissecting  out  these  cysts  rather  than  trusting  to 
the  uncertain  method,  formerly  so  much  in  vogue,  of  injecting 
them  with  irritative  and  corrosive  solutions. 

Adenomata  (General  Cystic  Disease)  of  the  Testis. — The 
tumours  of  the  testis  that  will  be  described  under  this 
heading  are  those  to  which  Astley  Cooper*  gave  the  name  of 
"hydatid  disease."  They  were  made  the  subject  of  careful 
study  by  Curling,f  who  designated  the  condition,  "  general 
cystic  disease  of  the  testis." 

The  morphology  of  these  tumours  has  been  investigated 

*  "  Diseases  of  the  Te&tis,  1830." 
t  Med.-Chir.  Trans.,  vol.  xxxvi.  449. 


TUBULO-CTSTS.  407 

independently  by  Eve*  and  myself.f  We  find  good  evidence 
that  they  originate  in  the  remnant  of  the  mesonephros 
(Wolffian  body)  which  lies  between  the  globus  major  of  the 
epididymis  and  the  testis  proper.  This  remnant  of  the 
mesonephros  is  known  as  the  j)aradidymis.  (Fig  211.)  It 
often  presents,  as  has  already  been  mentioned,  a  distinctly 
glandular  structure. 

Testicular  adenomata  in  their  typical  condition  are  made 
up  of  large  numbers  of  cystic  spaces.  These  cavities  vary 
greatly  in  size  ;  some  are  no  larger  than  rape-seed,  others  may 
attain  the  size  of  a  cob-nut.  Many  are  distinctly  tubular,  and 
the  cysts  may  communicate  with  each  other.  The  loculi  are 
lined  with  regular  columnar,  cubical,  or  stratified  epithelium, 
and  intracystic  papillomata  are  not  uncommon.  The  con- 
nective-tissue frame-work  of  the  tumour  consists  mainly  of 
simple  fibrous  tissue,  but  it  may  be  so  abundant  as  to  form 
the  bulk  of  the  tumour,  the  cysts  being  sparse.  In  some 
of  the  specimens,  especially  those  met  with  in  infants,  plain 
muscle  fibre  has  been  detected. 

In  at  least  one  instance  hair  has  been  detected  in  the  loculi 
of  a  testicular  adenoma.  J  Many  of  these  tumours  have  been 
described  as  cystic  sarcomata,  cystic  fibromata,  myxomata, 
etc. — all  unfortunate  names.  In  size  they  vary  greatly; 
specimens  are  known  as  large  as  melons.  The  best  examples 
for  investigation  are  those  which  do  not  exceed  the  size  of  an 
effsf.  In  these  the  relation  of  the  tumour  to  the  testicular 
structures  is  very  instructive.  As  the  tumour  increases  in  size 
it  flattens  the  body  of  the  testicle  until  it  is  reduced  to  a 
narrow  stratum  intervening  between  the  tunica  vaginalis  and 
the  adenoma.  (Fig.  213.)  In  the  large  specimens  it  is  often 
difficult  to  detect  any  remnant  of  the  testicle. 

Testicular  adenomata  have  been  observed  within  a  few 
months  of  birth  and  as  late  as  the  fortieth  year. 

In  all  strictness  testicular  adenomata  should  have  been 
described  in  chap.  xxvi. ;  but  as  they  are  so  closely  related  to 
the  vestiges  of  the  mesonephros,  it  was  more  convenient  to 
describe  them  in  this  chapter. 

*  Trans.  Path.  Soc,  vol.  xxxviii.  201. 

t  lancet,  1887,  vol.  i.  254. 

X  D'Arcy  Power,  Trans.  Path.  Soc,  vol.  xxxviii.  224. 


408 


CYSTS. 


Treatment. — The  most  satisfactory  method  of  dealing- 
with  paroophoritic  and  parovarian  cvsts  is  prompt  removal. 
Parovarian  cysts  are  the  simplest  and  most  satisfactory  cysts 
with  which  surgeons  have  to  deal ;  they  rarely  contract 
adhesion  and  are  almost  always  unilocular. 

Paroophoritic  cysts  stand  in  striking  contrast  to  those 
which  arise  in  the  parovarium,  for  they  burrow  deeply  beneath 


The  secreting  tissue  of  the  testis. 


•'  The  tumour. 
Fig.  213. — Testicular  adenoma.     (Museum,  St.  Mary's  Hospital.) 

the  pelvic  peritoneum  and  give  rise  to  great  difficulty  in 
consequence  of  the  close  proximity  of  such  structures  as  the 
ureter,  iliac  arteries  and  veins,  and  the  inferior  vena  cava. 
When  small  the}^  are  sometimes  reiuoved  as  easily  as 
parovarian  cysts,  but  when  large,  and  the}''  have  burrowed 
deeply,  the  process  of  enucleation  is  both  difficult  and 
dangerous.  The  presence  of  an  abundant  crop  of  warts,  or 
hydroperitoneum  should  not  deter  the  surgeon  from  removing- 
a  paroophoritic  cyst,  as  the  exudation  of  fluid  will  cease  and 
the  warts  disappear  when  the  cyst  is  removed. 

Cysts  in  the  vagina  due  to  vestiges  of  Gartner's  duct 
should  be  completely  dissected  out.  When  the  cyst  is  large 
the  surgeon  must  be  prepared  for  a  delicate  and  deep  dis- 
section that  may  lead  him  very  close  to  the  bladder  in  front. 


TFBULO-CYSTS.  409- 

the  ureter  at  the  side,  the  rectum  behmd  and  the  peritoneum 
above.  It  is  absohitely  necessary  to  dissect  out  the  whole  of 
the  cyst.     Measures  short  of  this  are  useless. 

The  most  satisfactory  njethod  of  treating  encysted  hydro- 
cele of  the  testis  is  to  expose  the  cyst  through  an  incision  in 
the  scrotum,  tap  the  cyst,  and  then  enucleate  its  walls,  taking 
care  not  to  damage  the  testis  or  the  vas  deferens.  The  cavity 
is  then  drained  and  allowed  to  close  by  granulations. 

Such  procedures  as  tapping  and  the  injection  of  irritating 
fluid  are  troublesome,  inconvenient,  and  often  end  in  dis- 
appointment. The  method  of  incising  the  cyst  and  stitching 
its  edges  to  the  skin  and  allowing  the  sac  to  granulate  is' 
practised  by  a  few  surgeons  :  it  is  slow  and  unsatisfactory 
when  compared  with  radical  extirpation  of  the  sac. 

There  are  no  signs  that  enable  a  surgeon  to  diagnose 
with  certainty  a  testicular  adenoma :  it  has  been  confounded 
with  hsematocele,  tubercular  disease,  and  sarcoma.  The 
appropriate  treatment  is  castration. 

Cysts  of  Mailer's  Ducts. — In  many  vertebrata  the  eggs,  after  their 
escape  from  the  ovary,  are  conveyed  to  the  exterior  by  means  of  a  muscular 
conduit  known  as  the  oviduct.  The  general  disposition  of  these  ducts,  for 
there  are  usually  two,  may  be  gathered  from  an  examination  of  a  female 
frog  or  toad.  The  ducts  extend  from  the  cloaca  posteriorly  to  the  roots  of 
the  lungs  anteriorly;  they  are  sup^jorted  on  the  dorsal  wall  of  the  abdomen 
by  means  of  a  delicate  fold  of  peritoneum,  and  each  duct  communicates 
with  the  peritoneal  cavity  by  a  dilated  orifice  known  as  the  infuudibulum. 
In  the  breeding  season  the  ducts  become  greatly  enlarged  and  convoluted, 
resembling  coils  of  small  intestine. 

Normally,  oviducts  are  present  in  the  female  only.  It  is,  however, 
remarkable  that  the  embryos  of  those  forms  in  which  the  sexes  are  distinct 
in  the  adult  condition,  have  the  rudiments  of  the  sexual  organs  peculiar  to 
the  male  and  female  ;  they  are  hermaphrodite.  As  development  continues 
one  set  of  organs  usually  attains  a  fvrnctioual  condition ;  the  other  atropines 
more  or  less  completely. 

The  distinguisliing  features  of  tlie  internal  sexual  organs  of  a  female 
frog  are  two  ovaries  and  two  oviducts.  In  the  male  the  oviducts  are 
usually  absent.  It  is,  however,  an  interesting  fact  that  in  many  male 
frogs  the  oviducts  may  be  detected  as  thin,  delicate  threads  ascending  in 
the  peritoneum  from  the  structures  called  vesiculse  seminales  to  the  roots  of 
the  lungs.  Sometimes  the  ducts  are  of  large  size,  almost  equal  to  the 
oviducts  in  the  female.  Persistent  Miillerian  ducts  are  more  common  in 
male  toads  than  in  frogs.  Often  they  are  associated  with  the  maKorma- 
tion  of   the  genital  gland  known  as  an  ovo-testis;    but  they  are  fairly 


410  CYSTS. 

frequent  even  when  the  genital  gland  is  a  typical  testis.  No  one  can 
doubt  that  an  oviduct  in  a  male  frog  or  toad  is  fuuctiouless,  and  it  is 
not  uncommon  to  meet  with  small  dilatations  or  cysts  lying  in  the  track  of, 
and  arising  from,  the  f unctionless  oviducts.  Persistent  MiiUer's  ducts  are 
by  no  means  confined  to  batrachiaus,  but  they  have  been  observed  in  fish, 
lizards,  stallions,  birds,  and  men. 

Good  examples  of  cysts  arising  in  functionless  ducts  are  sometimes 
met  with  in  birds.  In  birds,  as  in  frogs  and  toads,  the  eggs  are  conveyed  to 
the  exterior  by  means  of  an  oviduct,  but  in  the  case  of  ])irds  the  duct  is 
functional  on  the  left  side  only.  Each  chick  has  two  oviducts,  but  the 
right  ovary  and  duct,  from  some  unexplained  cause,  atrophies,  leaving,  as 
a  rule,  a  small,  narrow  tubule  surmounted  by  a  lobule  of  fat.  This 
remnant  of  the  right  duct  is  very  apt  to  dilate  and  form  a  cyst.  When 
the  stump  of  the  duct  is  longer  than  usual  it  will  sometimes  become 
unequally  dilated  and  form  a  chaplet  of  cysts. 


411 
CHAPTER    XLV. 

HYDROCELE. 

The  name  hydrocele  is  applied  to  several  different  kinds  of 
cystic  tumours,  and  as  the  name  is  so  deeply  rooted  in  surgical 
literature  it  would  be  very  inconvenient  to  attempt  to  discard 
it.  It  will  be  used  in  this  work  in  a  generic  sense,  and  will 
include  the  following  species :— (1)  Hydrocele  of  the  tunica 
vaginalis ;  (2)  Hydrocele  of  the  canal  of  Nuck ;  (3)  Ovarian 
hydrocele. 

(1)  Hydrocele  of  the  Tunica  Vaginalis. — Each  testicle 
is  preceded  in  its  descent  by  a  diverticulum  of  the  parietal 
peritoneum,  which  enters  the  scrotum  by  way  of  the  inguinal 
canal.  As  the  testicle  descends  behind  this  diverticulum,  or 
funicular  pouch  as  it  is  termed,  it  invaginates  the  membrane 
in  such  a  way  as  to  invest  the  anterior  two-thirds  of  its  surface 
with  a  double  layer  of  peritoneum.  When  the  testicle  first 
gains  the  scrotum  the  funicular  pouch  is  in  free  communica- 
tion with  the  general  peritoneal  cavity.  It  is  a  remarkable 
fact  that  in  almost  every  mammal,  male  and  female,  save 
man,  this  relation  of  the  funicular  pouch  to  the  peritoneal 
cavity  persists  throughout  life. 

In  exceptional  instances  this  communication  persists  even 
in  man,  but  in  him  it  is  distinctly  abnormal.  Normally  the 
peritoneum  becomes  adherent  immediately  above  the  testis, 
this  adhesion  dividing  the  pouch  into  two  parts ;  that  in 
relation  to  the  testis  persists  throughout  life  as  the  tunica 
vaginalis,  whilst  that  above  the  testis  usually  undergoes 
obliteration  in  the  course  of  the  early  months  of  infant  life. 
Occasionally,  occlusion  of  this  pouch  is  delayed  for  some  years, 
and  in  rarer  cases  it  may  persist  throughout  life. 

Normally,  the  only  portion  of  the  funicular  pouch 
that  persists  throughout  life  is  that  which  is  in  im- 
mediate relation  with  the  testis- — the  tunica  vaginalis — and 
when  this  becomes  distended  with  fluid  it  is  termed  hydro- 
cele of  the  tunica  vaginalis.  When  containing  blood  it  is 
called  hcematocele  of  the  tunica  vaginalis.  Should  the  whole 
of  the  funicular  pouch  persist  and  become  occupied  by  fluid, 


412 


CYSTS. 


Covering  of 

the  cord  - 


Cremaster  muscle 


Tunica  vaginal 


it  is  called  a  congenital  li.ydvocde.  Frequently  the  tunica 
vaginalis  is  formed  as  usual,  but  the  portion  intervening 
between  it  and  the  internal  abdominal  ring  persists,  and  may 
become  distended  with  fluid.  This  is  known  as  fv/nicidar 
Jtydvocele ;  it  is  often  called  encysted  hydrocele  of  the  cord. 

Hydrocele  of  the  Tunica  Vaginalis  appears  in  two  forms, 
acute  and  chronic.     Acute  hydrocele  is  due  to  inflammatory 

effusion  into  the  sac, 
either  as  the  result 
of  injury  or  second- 
ary to  acute  orchitis.  - 
This  is  the  rarer 
form  and,  as  a  rule, 
the  fluid  is  absorbed 
and  the  parts  return 
to  their  normal  con- 
dition as  the  inflam- 
matory trouble  that 
caused  it  subsides. 
Exceptionally,  a  hy- 
drocele appearing  in 
this  way  persists. 

The  common 
form  of  hydrocele  is 
a  passive  effusion 
into  the  tunica  vagi- 
nalis, usually  appear- - 
ing  about  the  middle 
period  of  life,  and  in 
most  cases  without  any  exciting  cause,  either  local  or  consti-- 
tutional.  It  is  very  common  in  men  As^ho  have  lived  in  the 
tropics.  This  form  of  hydrocele  is  not  infrequent  in  infants, 
but  as  a  rule,  quickly  disappears.  Hydrocele  is  met  with  in 
extreme  old  age,  and  is  occasionally  bilateral. 

The  amount  of  fluid  in  hydroceles  varies  greatly ;  in  some 
it  amounts  to  one  or  two  ounces,  whilst  in  others  it  measures 
a  pint  or  more.  It  is  related  of  Gibbon  the  historian,  that 
he  had  a  hydrocele  which  Cline  tapped  and  from  which  six 
quarts  of  fluid  were  drawn  off.     (Erichsen.) 

The  fluid  when  withdrawn  from  a  hydrocele  is  limpid,  of  a 


Hydrocele 


Testicle 


Fig.  214.— Hydrocele  of  the  tunica  vaginalis  testis 


TIYDR0CELE8.  413 

straw  colour,  with  a  sp.  gr.  of  about  1015.  It  contains  a  large 
amount  of  albumen  and  the  substance  known  as  fibrinogen. 
When  allowed  to  stand  after  withdrawal  it  spontaneously 
coagulates. 

When  the  fluid  is  removed  by  tapping,  it  usually  quickly 
reaccumulates,  so  that  the  amount  of  fluid  furnished  by  a 
large  hydrocele  in  the  course  of  a  few  years  is  often  consider- 
able. Even  the  withdrawal  of  large  quantities  of  fluid  from  a 
hydrocele  at  frequent  intervals  seems  to  exercise  no  evil 
influence  upon  the  health  of  the  patient. 

The  presence  of  a  large  quantity  of  fluid  in  the  tunica 
vaginalis  leads  to  changes,  not  only  in  the  membrane  itself, 
but  also  in  the  testicle,  for  this  gland,  pressed  upon  by  the 
fluid,  Avill  in  course  of  time  atrophy.  In  most  specimens  the 
testis  is  situated  in  the  lower  and  back  part  of  the  sac,  as 
in  Fig.  214.  In  those  cases  in  which  the  testis  is  inverted 
the  hydrocele  projects  posteriorly,  and  the  testis  lies  in  front 
and  at  the  upper  part  of  the  sac. 

In  addition  to  atrophy  of  the  testis,  the  diminution  in  the 
size  of  its  secreting  tissue  may  be  masked  by  great  thicken- 
ing of  its  tunica  albuginea,  a  condition  termed  periorchitis, 
which  is  by  no  means  infrequent  in  old  hydroceles,  especially 
those  which  have  been  repeatedly  tapped.  This  thickening, 
or  sclerosis,  manifested  by  the  immediate  covering  of  the  testis 
is  often  seen  in  the  tunica  vaginalis  throughout  its  whole 
extent,  and  in  some  cases  this  membrane  may  be  as  thick  and 
almost  as  hard  as  paste-board.  The  hardness  of  these  thick 
sacs  is  sometimes  increased  by  calcareous  matter.  When  such 
sacs  are  dissected  out  they  are  not  unlike  a  cocoa-nut  in  shape, 
size,  and  even  in  consistence.  Secondary  changes  of  this  kind 
may  be  due  to  repeated  attacks  of  inflammation  set  up 
by  tapping.  A  slight  degree  of  inflammation  following  this 
slight  operation  may  be  useful,  as  it  may  induce  adhesion  of 
the  serous  surfaces  and  lead  to  obliteration  of  the  sac.  This, 
however,  is  rarely  complete.  In  some  cases  bands  of  adhesions 
or  broad  septa  form  and  produce  a  loculated  cyst.  In  other 
cases  suppuration  ensues  which  may  lead  to  serious  con- 
sequences. Occasionally,  loose  bodies  are  found  in  the  sac 
of  the  tunica  vaginalis,  often  associated  with,  but  sometimes 
independent  of,   hydroceles.      Some  are  no  larger  than  the 


414  CYSTS. 

head  of  a  pin  others  attain  the  dimensions  of  a  cherry.  The 
larger  examples  consist  of  dense  structureless  laminse. 

The  variety  known  as  Cong-enital  Hydrocele  is  due  to  the 
persistence  of  the  funicular  pouch  throughout  its  whole 
extent.  In  this  form  we  meet  with  two  conditions — viz.,  the 
sac  may  retain  its  connection  with  the  general  peritoneal 
cavity,  or  it  may  be  occluded  at  the  internal  abdominal  ring. 
When  the  orifice  of  the  sac  is  not  occluded,  the  fluid  that 
accumulates  in  the  sac  gravitates  into  it  from  the  peritoneal 
cavity  during  the  day  ;  but  during  the  night,  when  the  body 
has  been  in  a  recumbent  position  for  a  prolonged  period,  the 
fluid  returns  wholly  or  in  part  into  the  abdomen,  so  that  in 
the  morning  the  scrotal  swelling  will  be  found  greatly 
diminished,  if  not  entirely  gone.  As  the  day  goes  on  the 
fluid  will  slowdy  reaccumulate  in  the  tunica  vaginalis.  This 
alteration  in  size  of  the  swelling  is  characteristic  of  this 
variety  of  hydrocele ;  but  it  is  sometimes  simulated  by,  and 
mistaken  for,  inguinal  hernia. 

When  the  funicular  pouch  is  shut  off  at  the  inguinal  canal 
and  becomes  distended  with  fluid  it  is  difiicult  to  distinguish 
it,  except  by  dissection,  from  a  hydrocele  of  the  tunica 
vaginalis. 

Congenital  hj^lrocele  is  most  commonly  met  with  in 
children,  and  is  very  rare  after  the  fifteenth  year. 

Funicular  Hydrocele  is  another  variety  frequently  referred 
to  as  encysted  hydrocele  of  the  cord.  It  is  due  to  effusion 
of  fluid  into  that  portion  of  the  funicular  pouch  which  inter- 
venes between  the  tunica  vaginalis  and  the  internal  abdominal 
ring,  and  which,  under  normal  conditions,  suffers  obliteration. 
This  form  of  hydrocele  is  very  frequent  in  infants,  and  presents 
itself  as  an  ovoid  tumour  lying  between  the  testis  and  the 
inguinal  canal.  Although  it  possesses  very  characteristic 
features,  this  variety  of  hydrocele  is  frequently  confounded 
with  hernia  of  the  intestines  into  the  funicular  pouch. 
Funicular  hydroceles  occasionally  occur  in  3^oung  adults. 

It  should  be  borne  in  mind  that  an  inguinal  hernia  may 
be  associated  with  a  hydrocele,  and  it  happens  very  rarely 
that  the  neck  of  a  hernial  sac  may  become  so  narrowed  that 
gut  and  omentum  no  longer  pass  through  it.  A  pouch  of 
this  kind  would,  if  distended  with  fluid,  simulate  a  hydrocele 


HYDROCELES.  415 

of  the  tunica  vaginalis.  In  exceptional  cases,  hydrocele 
of  a  hernial  sac  accompanies  ascites.  In  several  instances 
collections  of  ascitic  fluid  have  been  evacuated  through 
trocars  inserted  into  the  sac  of  an  old  hernia. 

(2)  Hydrocele  of  the  Canal  of  Nuck.— In  female  foetuses 
a  diverticulum  of  the  parietal  peritoneum  descends  into  the 
inguinal  canal,  and  is  in  all  respects  identical  with  the 
funicular  pouch  in  the  male,  and  is  known  as  the  canal  of 
Nuck.  Usually  this  pouch  becomes  obliterated,  but  it  is  by 
no  means  rare  to  find  it  patent  in  young  females.  Occasion- 
ally the  canal  becomes  distended  with  fluid  and  forms  a  cyst 
occupying  the  inguinal  canal,  and  is  then  termed  a  hydrocele 
of  the  canal  of  Nuck. 

Treatment  of  Hydroceles. — The  routine  practice  of  treat- 
ing hydroceles  is  to  draw  off  the  fluid  by  means  of  a  narrow 
trocar  and  cannula.  The  cyst  almost  invariably  refills,  neces- 
sitating repeated  tapping.  To  remedy  this,  various  plans,  such 
as  injecting  the  sac  with  tincture  of  iodine,  carbolic  acid,  and 
good  port  wine,  have  been  employed.  Some  surgeons  incise 
the  sac  and  stuff  it,  permitting  the  Avails  to  granulate.  The 
most  satisfactor}^  method  is  to  expose  the  tunica  vaginalis  and 
dissect  it  away.  I  have  practised  this  radical  method  on 
patients  as  young  as  fifteen  months  and  as  old  as  eighty-three 
years.  It  is  the  most  satisfactory  and  successful  of  all  methods, 
and  is  safer  than  the  uncertain  plan  of  injecting  irritating 
fluids  into  the  sac. 

(3)  Ovarian  Hydrocele. — The  ovaries  in  rats  and  mice  are 
contained  within  a  serous  sac  derived  from  the  peritoneum. 
The  abdominal  ostium  of  the  Fallopian  tube  communicates 
with  the  ovarian  sac ;  hence  when  the  ova  escape  from  the 
ovary  they  enter  the  Fallopian  tube  and  gain  the  uterus  with- 
out entering  the  general  peritoneal  cavity,  as  is  the  case  with 
the  human  ovum.  This  serous  sac  investment  of  the  ovary 
reminds  us  of  the  tunica  vaginalis  of  the  testicle,  and  like  it 
the  ovarian  sac  is  liable  to  become  distended  with  serous  fluid, 
a  condition  to  which  I  have  applied  the  name  ovarian  hydro- 
cele. Cysts  of  this  kind  in  rats  may  attain  a  large  size,  and 
their  general  features  are  well  illustrated  in  Fig.  215.  The 
Fallopian  tube  in  the  rat  is  coiled  up  between  the  cornu  of 
the   uterus  and  the  ovarian  sac,  but  when  the  sac  becomes 


416 


CYSTH. 


distended  it  uncoils  the  tube  and  stretches  it  around 
the  circumference  of  the  cyst;  the  tubal  ostium  opens  on 
the  inner  wall  of  the  hydrocele,  and  the  adjacent  section  of 
the  tube  is,  as  a  rule,  dilated.  The  ovary,  when  the  cyst  is 
small,  projects  into  the  cyst,  but  in  very  large  hydroceles  it 
atrophies  from  pressure.  As  the  ovarian  sac  is  in  communica- 
tion with  the  uterine  cornu  it  sometimes  becomes  implicated 

in  septic  conditions 
of  the  uterus,  and 
the  sac  is  sometimes 
found  distended  with 
pus. 

No  mammal  nor- 
mally possesses  such 
;  a  complete  ovarian 
sac  as  do  rats  and 
mice,  but  many  have 
a  pouch  that  com- 
municates with  the 
general  peritoneal 
cavity  by  a  small 
aperture ;  in  others 
the  pouch  has  a 
narrow  slit ;  whilst 
in  women  the  ovary,  in  its  virgin  condition,  lies  in  a  shallow 
recess.  Notwithstanding  the  fact  that  the  mouth  of  the  ovarian 
pouch  is  in  women  very  Avide,  there  is  good  reason  to  beUeve 
that  its  edges  may  unite  when  the  pouch  is  abnormally  deep 
and  convert  it  into  a  closed  sac,  which  subsequently  becomes 
a  hydrocele.  Ovarian  hydroceles  occur  in  the  human  female 
and  sometimes  attain  a  large  size.  They  present  the  following 
anatomical  features : — 

The  sac  projects  from,  and  is  intimately  connected  with, 
the  posterior  layer  of  the  broad  ligament.  In  small  hydro- 
celes the  ovary  projects  into  the  cavity  of  the  cyst,  but  in 
large  examples  it  is  atrophied.  The  Fallopian  tube  lies  on  the 
crown  of  the  cyst,  its  outer  half  is  dilated  and  tortuous ;.  the 
ostium  opens  into  the  hydrocele  by  a  large  circular  or  ellip- 
tical aperture.  Ridges  of  mucous  membrane  issue  frona  the 
interior  of  the  tube  and  pass  on  to  the  walls  of  the  hydrocele 


Fig.  215.  — Ovarian  liydrocele  in  a  rat.     (Nat. 


HYDROCELES. 


417 


in  a  radiating  fashion.  When  the  specimens  are  examined  in 
a  fresh  state  it  is  not  rare  to  find  the  aj)erture  fringed  with 
tubal  timbricTe.  The  general  appearance  of  a  typical  ovarian 
hydrocele  suggests  "  a  retort  with  a  convoluted  delivery-tube  " 
(Griffith).     In  some  of  the  specimens  (Fig.  216)  there  appear 


VESTIBULE 


Fig.  216. — Ovarian  Iiydrocelc  :  the  interior  of  the  sac  is  beset  with  warts. 

to  be  three  parts  : — (1)  The  dilated  ampulla  of  the  tube,  which 
opens  by  its  fringed  ostium  into  (2)  a  vestibule,  which  opens 
into  (3)  the  hydrocele  proper.  In  women  the  hydrocele 
contains,  as  a  rule,  serous  fluid,  but  it  is  easy  to  understand, 
considering  its  relations  with  the  tube,  that  if  the  latter 
become  septic  the  hydrocele  would  become  filled  with  pus. 

I  have  never  been  able  to  demonstrate  an  epithelial  in- 
vestment on  the  inner  wall  of  an  ovarian  hydrocele,  but  warts 
may  occur  in  great  number.  The  ovary  may  be  cystic  and 
mask  the  nature  of  the  specimen,  and  greater  obscurity  pre- 
vails when  an  ovary,  associated  with  a  hydrocele,  contains  a 
dermoid.     Besides  findins-  them  in  rats  and  women,  I  have 


418  CYSTS. 

detected  an  ovarian  hydrocele  in  a  guinea-pig,  and  Schnei- 
demlilil  has  observed  it  in  the  mare. 

The  cysts  hable  to  be  confounded  with  ovarian  hydro- 
celes are  parovarian  cysts :  small  paroophoritic  cysts  and 
large  hydrosalpinges.  A  parovarian  or  paroophoritic  cyst  is 
distinguished  from  a  hydrocele  of  the  ovary  by  the  fact  that 
the  Fallopian  tube  is  stretched  across  the  cyst  but  does  not 
communicate  with  its  cavity. 

In  the  case  of  a  large  hydrosalpinx  the  ampulla  is  often  so 
flexed  on  the  tube  as  to  produce  a  retort-shaped  cyst ;  but 
there  are  no  fringes  or  ridges  of  the  mucous  membrane  at  the 
orifice  of  communication,  and  the  ovary  lies  free  of  the  cyst- 
wall  and  is  often  lodged  in  the  flexure  of  the  tube. 

Ovarian  hydroceles  must  not  be  confounded  with  tubo- 
ovarian  cysts  and  abscesses  the  result  of  salpingitis. 

Ovarian  hydroceles  demand  careful  study;  they  are  often  a 
source  of  difficulty  in  diagnosis,  and  their  appearance  is  some- 
times puzzling  to  beginners  in  abdominal  surgery,  and  their 
successful  removal  occasionally  an  anxious  proceeding. 


419 


CHAPTER  XLYI. 

CONGENITAL    CYSTS    (HYDROCELES)    OF    THE  NECK    AND    AXILLA. 

The  term  "  hydrocele  of  the  neck  ''  has  been  used  in  a  generic 
sense  for  various  congenital  cysts  occasionally  found  in  the 
anterior  and  lateral  regions  of  the  neck.     (Fig.  217.) 

The  term  should  be  reserved  for  those  congenital  cysts 
with  serous  contents  situated  beneath  the  deep  cervical  fascia. 
These  cysts  present  easily  recognisable  characters.  They  are 
always  noticed  at  or  immediately  after  birth  ;  even  at  birth 
they  are  sometimes  of  very  large  size,  and  exhibit  a  preference 
for  the  anterior  triangle,  and  in  some  instances  extend  mto  the 
axilla  and  superior  mediastinum ;  sometimes  they  occupy  the 
middle  line  of  the  neck,  and  occasionally  project  into  the 
posterior  triangle.  Their  upward  limit  is,  as  a  rule,  indicated 
by  the  hyoid  bone,  but  they  have  been  known  to  reach  as 
high  as  the  parotid  gland.  The  cyst  may  be  unilateral 
or  bilateral;  it  may  consist  of  a  single  cavity,  or  be  multi- 
locular,  and  the  various  chambers  may  intercommunicate. 
In  size  they  vary  greatly  ;  some  equal  a  fist,  others  are  bigger 
than  the  head  of  the  patient.  When  the  walls  of  the  cyst 
are  thin  and  the  overlying  skin  is  stretched,  the  tumour  is 
as  translucent  as  a  thin-walled  hydrocele  of  the  tunica 
vaginalis  testis. 

These  cysts  originate  below  the  deep  cervical  fascia,  but  a 
portion  may  make  its  way  through  this  membrane  and  become 
subcutaneous.  The  fact  that  these  cysts  always  arise  beneath 
the  deep  cervical  fascia,  gives  colour  to  the  view  that  they 
may  be  in  some  way  related  to  the  air-sacs  which  exist  in  this 
situation  in  many  monkeys.  In  their  anatomical  relationship 
and  the  way  they  ramify  among  the  big  vessels  at  the  root  of 
the  neck,  cervical  cysts  in  children  and  cervical  air-sacs  in 
monkeys  are  on  all-fours. 

It  is  possible,  indeed  very  probable,  that  some  of  these 
congenital  cysts  of  the  neck  arise  as  dilatations  of  lymphatics. 
On  several  occasions  I  have  dissected  foetuses  born  at  fnU- 
time  with  large  subcutaneous  cysts  on  the  back  and  the 
abdomen  filled   with   straw-coloured  fluid,   and   in   at  least 


420 


CYSTS. 


one  instance  a  cervical  cyst  has  been  associated  with  rnacro- 
glossia.*  Some  of  these  cysts  remind  me  of  the  large  lymph- 
spaces  beneath  the  skin  of  frogs. 

Perhaps  the  most  remarkable  fact  in  connection  with 
them  is  the  tendency  they  exhibit  to  shrivel  and  disappear ; 
they  are  exceptionally  liable  to  inflame,  and  several  cases  have 
been  recorded  in  which  they  have  been  burst  by  the  children 


Fig.  217.— Congenital  cervical  cyst  extending  into  the  axilla.    (After  T.  Smith.) 


falling  upon  them.  Their  proneness  to  spontaneous  cure 
explains  the  extreme  rarity  of  these  cysts  after  puberty. 
Attempts  to  cure  them  by  tapping,  injections,  or  setons  are 
usually  attended  by  grave  danger ;  this  is  equally  true  when 
the  surgeon  tries  to  remove  them,  as  the  dissections  are 
deep  and  tedious,  and  complete  extirpation  is  sometimes 
impossible. 

It  has  been  many  times  observed  that  the  spontaneous 
effacement  of  these  cysts  is  preceded  by  a  sudden  increase  in 
their  size ;  they  become  hot,  tender,  and  pass  into  a  state  of 
inflammation,  and  as  this  subsides  the  C3^sts  slowly  disappear. 

*  Maguire,  .Journal  of  AxatouDj  and  FJiysioIogij,  vol.  xiv.  416. 


HTDEOOELES   OF   THE  NEGK. 


421 


Congenital  cervical  cysts  do  not  always  atroj^liy.  Birkett* 
has  recorded  the  details  of  a  case  in  which  one  of  these  cysts 
was  observed  in  the  neck  just  above  the  clavicle  soon  after 
birth ;  it  gradually  increased  in  size  and  extended  into  the 
axilla.     When  the  patient  was  three  years  of  age  the  cyst  was 


X 


Fig.  218.— Congenital  cervical  cyst  in  a  man  twenty  years  of  age.    {Aftur  Birkett.) 

tapped  and  nine  ounces  of  clear  serum  were  withdrawn. 
Severe  constitutional  symptoms  followed  this  procedure,  the 
life  of  the  patient  being  placed  in  great  jeopardy.  The  child 
recovered  and  in  a  short  time  the  cyst  refilled.  Mr.  Birkett  did 
not  see  this  boy  again  until  he  was  twenty  years  old.  He  then 
presented  himself  at  Guy's  Hospital  with  the  tumour  in  the 
condition  represented  in  Fig.  218,  and  as  it  caused  the  man 

*  Med.-Chir.  Trans.,  vol.  li.,  p.  185. 


422 


CYSTS. 


miicli  inconvenience  he  was  anxious  to  get  rid  ol  it.  Attempts 
were  made  to  cure  the  cyst  by  withdrawing  the  fluid  by 
repeated  tappings.  In  the  course  of  seventeen  days  five 
punctures  were  made,  and  in  all  one  hundred  and  eighty-one 
ounces  of  dark-brown  serous  fluid  flowed  out ;  but  this  treat- 
ment made  no  difference  to  the  tumour,  and  as  it  seemed  to 
affect  the  patient  profoundly,  it  was   deemed   prudent  not 

to  resort  to  more  active  mea- 
sures, and  the  man  returned 
to  his  home. 

It  is  necessary  to  point 
out  that  in  some  of  these 
cervical  cysts,  as  well  as  those 
Avhich  occur  in  the  axilla — 
for  cysts  of  this  character  are 
\         -*_-._— —-^    ^  sometimes  met   with   in   the 

r      ^^^  ^       ^\^       axilla  unassociated  with  cer- 

vical cysts — the  walls  consist 
of  tissue  so  vascular  as  to 
merit  the  term  nsevoicl.  In 
some  of  the  cases  that  have 
been  carefully  observed  and 
dissected,  the  tissue  so  strongly 
resembled  erectile  tissue  that 
some  writers  have  considered 
that  these  cysts  should 
be  regarded  as  nsevi  that 
have  undergone  cystic  de- 
generation, and  some  have 
even  ventured  the  opinion  that  they  arise  in  the  intercarotid 
body,  a  theory  which  Luschka  regarded  as  probable.  Julius 
Arnold'^  effectually  disposed  of  this  conjecture  by  pubHshing 
details  of  two  cases  which  he  dissected,  in  which  he  found  in 
addition  -to  the  cyst  an  intercarotid  body. 

It  is  also  necessary  to  point  out  that  congenital  cysts  of 
this  character  are  met  with  on  the  thorax,  unassociated 
with  cervical  cysts  (Fig.  219).  Birkett,  in  the  paper  previously 
mentioned,  has  described  two  cases  in  which  he  enucleated 


Fig.  219. — Congenital  cyst  of  the  thorax  with 
iifevoid  walls.     {After  Hutchinson.) 


*  Virchow's  "  Archiv,"  bd.  xxxiii.,  s.  209. 


HYDB0GELE8   OF   THE  NEGK.  423 

a  nsevoid  cyst  from  the  axilla.  Similar  cysts  have  been 
observed  and  described  by  surgeons  on  the  back  and  even 
on  the  limbs. 

In  concluding  this  account  of  congenital  cervical  and 
axillary  cysts  it  is  well  to  point  out  that  some  of  them 
probably  arise  on  the  same  plan  as  the  laryngeal  saccules 
of  certain  apes  :  a  few  may  be  due  to  secondary  changes 
in  nsevi,  and  others  may  originate  in  the  lymphatics. 

Some  of  the  smaller  unilateral  cysts  confined  to  the 
neighbourhood  of  the  sterno-mastoid  are  due  to  the  distension 
of  imperfectly  obliterated  branchial  clefts.  These  are  fully 
dealt  with  in  chap.  xxxv.  Lastly,  it  must  not  be  forgotten 
that  typical  dermoids,  with  skin,  hair,  and  even  teeth,  are 
occasionally  met  with  in  the  neck. 

Laryngoceles. — In  certain  adult  monkeys,  particularly  the 
chimpanzee  (Simia  troglodytes)  the  deep  cervical  fascia  is 
undermined  by  diverticula  from  the  laryngeal  mucous  mem- 
brane. This  large  sub-fascial  air-chamber  communicates  with 
the  larynx  through  the  thyro-hyoid  membrane  ;  it  extends 
downwards  to  Avithin  2  cm.  of  the  pre-sternum.  Exceptionally 
it  dips  into  the  anterior  mediastinum,  and  laterally  into 
the  arm-pits,  the  axillary  fascise  forming  the  lowest  limits 
of  the  sac. 

In  one  fine  chimpanzee  I  injected  this  huge  reservoir, 
and  found  it  would  hold  three  pints  of  injection  mass.  In  the 
Howling  monkeys  (Mycetes)  the  air-sac  is  very  large,  and  the 
basi-hyal  is  hollowed  to  form  a  resonance  chamber.  Cervical 
air-sacs  exist  in  many  mammals,  and  can  be  inflated  at  will. 
They  arise  as  diverticula  from  the  larynx,  either  from  the 
ventricle,  or  from  the  pouch  of  Morgagni  in  the  middle 
line  of  the  larynx  below  the  epiglottis.  In  the  early  stages 
the  lateral  pouch  resembles  the  human  sacculus  laryngis 
inflated.  Gradually  the  sacs  undermine  the  deep  cervical 
fascia  and  subsequently  coalesce.  The  air-sac  of  the  adult 
chimpanzee  is  formed  by  fusion  of  two  lateral  and  a  median 
pouch. 

There  is  great  variety  in  the  degree  of  development 
of  the  cervical  sacs  in  difl'erent  genera  and  species  of 
mammals. 

In  1888  I  stated  the  following  reasons  for  regarding  some 


424  CYSTS. 

kinds  of  congenital  cervical  cysts  in  children  as  examples  of 
laryngeal  saccules : — 

1.  The   congenital   nature   of  the  cysts.     Kepetitions   of 

animal  structures  of  this  kind  are  always  congenital. 

2.  Their  relation  to   the   hyoid   bone   and  larynx.      The 

hollow  of  the  basi-hyal  in  man  represents  the  large 
cavity  in  the  basi-hyal  of  many  mammals. 

3.  The  situations  of  the  cysts  beneath  the  deep  cervical 

fascia  and  their  occasional  extension  into  the  axillae. 
Treatment. — It  has  already  been  mentioned  that  "hydro- 
celes of  the   neck"  very  rarely  require  treatment,   as    they 
almost  invariably  shrivel  and  disappear  spontaneously. 


425 


CHAPTER  XLYII. 

CYSTS   OF   THE   SALIVARY   GLANDS — RANULyE — PANCREATIC 
CYSTS — DACRYOPS. 

The  term  ranula  is  probably  one  of  the  oldest  in  surgery, 
and  its  etymology  is  not  very  obvious.  Until  recently  it  was 
applied  to  all  cysts  in  tlie  floor  of  tlie  mouth,  and  as  cysts  in 
this  situation  are  of  various  kinds  and  arise  from  difterent 
structures,  it  naturally  followed  that  the  term  gradually  came 
to  possess  merely  a  topographical  significance.  There  is  at 
the  present  time  a  strong  tendency  to  restrict  the  name 
ranula  to  cysts  arising  in  connection  with  the  ducts  of  the 
three  sets  of  salivary  glands  opening  into  the  mouth,  and  to 
designate  them  as  submaxillary,  sublingual,  or  parotid  ranulse, 
according  to  the  gland  affected.  If  surgeons  would  use  the 
term  in  this  definite  sense  much  unnecessary  discussion  would 
be  saved. 

In  the  majority  of  cases  ranulas  are  probably  retention 
cysts  due  to  obstruction  of  a  duct.  They  are  common  in 
connection  with  the  submaxillary  and  sublingual  glands. 
The  cysts  are,  as  a  rule,  thin-walled,  and  lie  in  the  furrow 
between  the  gum  and  the  tongue  and  bulge  upwards  into 
the  floor  of  the  mouth.  When  large  they  cause  a  prominence 
in  the  submaxillary  triangle.  The  cyst  may  be  filled  with 
saliva.  Sometimes  it  contains  mucus  and  a  yellow  substance 
resembling  the  yolk  of  an  egg. 

Occasionally  the  obstruction  is  caused  by  a  calculus 
impacted  in  the  orifice  of  the  duct,  but  cases  come  under 
observation  in  which  the  duct  is  not  completely  obstructed, 
yet  the  fluid  is  retained.  It  is  reasonable  to  believe  that 
ranulse  sometimes  arise  independently  of  obstruction  to  the 
main  duct,  and,  as  in  the  case  of  pancreatic  so-called  ranulse, 
observation  supports  the  view  that  there  is,  in  all  probability, 
a  pathological  cause  apart  from  mere  obstruction  concerned 
in  their  production. 

Parotid  ranulae  are  rare  in  the  human  subject,  but  they 
have  been  observed  in  calves,  oxen,  and  horses. 


426  CYSTS. 

Submaxillary  and  sublingual  ranuke  occasionally  follow 
amputation  of  the  tongue,  due,  no  doubt,  to  injury  of  the 
duct  or  its  implication  in  cicatricial  tissue. 

Much  needless  discussion  has  taken  place  in  regard  to 
the  sources  of  ranulte,  because  the  various  writers  seem  to 
forget  that,  in  addition  to  salivary  glands,  there  are  mucous 
glands,  and  one  of  variable  size  near  the  tip  of  the  tongue 
known  as  Nuhn's  gland.  Any  of  these  may  dilate  into  a 
cyst.  Still  further  to  complicate  the  diagnosis,  dermoid  cysts 
not  infrequently  arise  in  the  floor  of  the  mouth  near  the 
frsenum  of  the  tongue  or  deeply  in  its  substance  (see  page 
308).  It  has  also  been  urged  as  an  objection  to  the  view 
that  ranulse  arise  in  the  ducts  of  the  salivary  glands,  that 
the  fluid  they  contain  is  not  always  saliva.  This  is  very  weak 
argument.  Many  hydronephrotic  cysts  contain  fluid  which 
it  would  be  difficult  to  regard  as  urine,  and  an  obstructed 
gall  bladder  is  sometimes  filled  with  fluid  that  does  not  possess 
a  single  attribute  of  bile.  So  a  cyst  arising  in  connection  with 
a  salivary  gland  will  sometimes  contain  fluid  that  fails  to 
furnish  the  characteristic  reactions  of  saliva. 

Treatment. — The  method  of  treating  a  ranula  consists  in 
excising  a  portion  of  the  wall  of  the  sac,  evacuating  the 
contents,  stuffing  the  cyst,  and  allowing  it  to  granulate.  It  is, 
however,  much  more  satisfactory  to  dissect  out  the  whole  of 
the  cyst.  This  is  an  insurance  against  its  return,  and,  as 
surgical  wounds  of  the  mouth  heal  rapidly,  recovery  after 
complete  extirpation  of  the  cyst  is  quicker  and  more  complete 
than  when  the  sac  is  left  to  obliterate  by  granulation. 

Pancreatic  Cysts. — It  has  long  been  known  that  the  duct 
of  the  pancreas  is  liable  to  become  dilated,  and  as  the  con- 
dition is  analogous  to  the  distension  of  the  ducts  of  the  buccal 
salivary  glands,  dilatation  of  the  pancreatic  duct  (canal  of 
Wirsung)  is  sometimes  referred  to  as  a  "  pancreatic  ranula." 

Virchow  recognised  two  varieties  of  pancreatic  ranula.  In 
one  variety  the  canal  is  dilated  irregularly  throughout  its 
whole  extent,  so  that  it  assumes  the  appearance  of  a  chaplet  of 
cysts  ;  in  the  other  the  duct  is  dilated  immediately  behind  its 
terminal  orifice.  Such  cysts,  he  writes,  may  attain  the  size  of 
a  fist,  and  are  consecutive  to  cicatricial  contractions  and  com- 
pression by  tumours.      The  cysts  are  not  filled  simply  with 


GYSTS   OF  SALIVARY  GLANDS.  427 

pancreatic  secretion,  for  when  the  cysts  attain  a  certain  size 
they  will  be  found  to  contain  mucoid  material,  products  of 
haemorrhages,  and,  not  rarely,  calculi.  Judging  from  what  is 
known  of  retention  cysts  in  general  it  would,  as  a  matter  of 
simple  inference,  be  thought  that  pancreatic  ranulas  arise 
from  partial  obstruction  to  the  pancreatic  duct,  either  from 
impaction  of  a  pancreatic  calculus  in  the  terminal  segment 
of  the  duct,  a  gall-stone  lodged  at  the  duodenal  orifice,  or  a 
tumour  arising  in  connection  with  the  ducts  or  tissues,  in  the 
immediate  neighbourhood.  This,  however,  does  not  appear 
to  be  the  case,  for  pancreatic  ranulse  have  been  observed  and 
no  obstruction  has  been  detected  by  the  most  careful  dissec- 
tion. Besides  this,  the  duct  of  the  pancreas  has  been  found 
completely  obstructed  by  a  calculus,  and  the  gland,  instead 
of  being  converted  into  a  cyst,  has  been  found  atrophied, 
its  secreting  elements  being  largely  replaced  by  fibrous  tissue. 

Experimental  evidence  also  supports  this  conclusion,  for 
it  has  been  demonstrated  that  when  the  pancreatic  duct  is 
occluded  during  life  by  a  ligature  the  gland  does  not  become 
cystic,  but  atrophies.  Thus  experimental  and  clinical  evidence 
indicates  that  pancreatic  cysts  are  the  result  of  pathological 
changes  which  may,  or  may  not,  be  associated  with  obstruction 
of  the  duct. 

A  great  deal  of  attention  has,  during  the  past  ten  years, 
been  devoted  to  pancreatic  cysts  in  their  clinical  as  well  as 
their  pathological  aspect,  and  certainly  the  evidence  indicates 
that  other  causes  than  obstruction,  partial  or  complete,  are 
responsible  for  their  production. 

Cysts  described  as  pancreatic  sometimes  attain  very  large 
proportions,  and  examples  have  been  reported  with  a  capacity 
of  two  gallons  or  more.  These  very  big  cysts  form  smooth 
globular  swellings  in  the  upper  part  of  the  belly.  They 
lie  behind  the  peritoneum,  and  of  course,  have  the  stomach 
and  transverse  colon  in  front ;  when  very  large  these  cysts  will 
extend  some  distance  below  the  transverse  colon. 

The  fluid  contained  in  large  pancreatic  cysts  is  usually 
turbid.  Sometimes  it  is  Avhite  or  even  opalescent,  occasionally 
it  is  clear,  and  in  some  cysts  it  will  have  a  brown  or  even  a 
green  tint.  The  specific  gravity  varies  between  1010  and 
1020,  and  there  is  a  small  trace  of  albumen.      Mucin  is  often 


428  CYSTS. 

present,  also  tyrosin  and  blood  pigment:  and  traces  of"  urea 
have  been  detected.  The  fluid  is  sometimes  capable  of  emul- 
sifying fats. 

The  modes  by  which  very  large  pancreatic  cysts  arise  is 
not  by  any  means  clear,  but  it  is  important  to  bear  in  mind 
that  there  is,  in  a  very  significant  proportion  of  cases,  a 
definite  history  of  antecedent  injury.  This  fact  gives  colour 
to  the  suggestion  that  some  of  the  cysts  are  due  primarily  to 
laceration  of  the  pancreas  and  subsequent  extravasation  of 
its  secretion  behind  the  peritoneum.  Another  very  impor- 
tant feature  of  these  cysts  is  the  liability  to  haemorrhage, 
and  this  may  take  place  so  abundantly  into  the  cyst  as  to 
jeopardise  the  life  of  the  patient ;  indeed  in  some  cases  it 
has  been  fatal. 

Pancreatic  cysts  occur  at  almost  all  periods  of  life.  Ex- 
amples have  been  reported  as  early  as  the  eighth  year  of  life 
and  as  late  as  the  seventy-third.  They  appear  to  be  most 
frequent  in  men,  but  a  number  of  cases  have  been  reported 
in  women. 

Pancreatic  cysts  attributed  to  injury  have  followed  a 
variety  of  accidents,  such  as  falls  from  a  great  height, 
followed  by  abdominal  pain ;  a  crush  of  the  abdomen 
between  the  buffers  of  railway  waggons ;  fall  from  a  horse, 
or  from  a  vehicle  ;  kicks  from  men,  and  in  several  cases  from 
horses. 

Jordan  Lloyd*  has  attempted  to  show  that  the  large 
pancreatic  cysts  that  follow  injury  to  the  abdomen  are  really 
collections  of  fluid  in  the  cavity  of  the  lesser  omentum,  and 
when  the  fluid  has  the  property  of  rapidly  converting  starch  into 
sugar  it  may  be  assumed  that  the  pancreas  has  been  injured. 
He  also  points  out  that  the  characteristic  feature  of  so-called 
pancreatic  cysts — viz.,  a  swelling  occupying  the  epigastric, 
umbilical,  and  left  hypochondriac  regions — is  precisely  that 
which  would  result  from  distension  of  the  lesser  bag  of  the 
peritoneum.  It  is  probable  that  some  cases  of  supposed 
pancreatic  cysts  were  really  effusions  into  the  lesser  bag  of  the 
peritoneum,  for  undoubted  examples  of  distension  of  this 
cavity  with  fluid  have  been  observed,  dissected,  and 
described. 

*  £rit.  Med.  Journal,  1892,  vol.  ii.  1051. 


CYSTS   OF  SALIVABY  GLANDS.  429 

Treatment. — The  method  of  treatment  that  gives  best 
results  is  to  expose  the  cyst  through  an  abdominal  incision, 
and,  after  emptying  the  cyst,  stitch  its  cut  edges  to  the 
margins  of  the  wound  in  the  belly-wall  and  drain  ;  it  is  also 
desirable  to  make  a  counter-opening  into  the  cavity  of  the 
cyst  through  the  loin. 

Our  knowledge  of  pancreatic  cysts  has  been  greatly  in- 
creased since  Senn*  of  Chicago  drew  attention  to  them 
in  1885.  Active  surgical  treatment  of  pancreatic  cysts  has 
been  the  consequence,  and  it  has  been  accompanied  by 
remarkable  success. 

Chyle  Cysts. — This  is  perhaps  the  best  place  to  mention  a 
rare  but  interesting  kind  of  tumour  which  would  certainly 
complicate  the  diagnosis  of  a  pancreatic  cyst.  It  is  known  as 
chyle  cyst  of  the  mesentery.  The  sac  of  the  cyst  appears  to 
be  formed  of  the  separated  layers  of  the  mesentery,  the  inter- 
space being  occupied  by  fluid  identical  in  its  physical  and 
chemical  characters  with  chyle.  Such  tumours  sometimes 
attain  very  large  sizes.  They  require  the  same  treatment  as 
pancreatic  cysts. 

Dr.  Adolph  Raschf  has  written  an  excellent  account  of  a 
typical  example  of  chyle  cyst. 

Dacryops. — This  term  is  applied  to  cysts  occurring  in  the 
upper  eyelid ;  they  are  due  to  distension  of  the  ducts  of  the 
lachrymal  gland.  They  appear,  as  a  rule,  in  the  upper  and 
outer  part  of  the  eyelid,  the  cyst  extending  beneath  the  border 
of  the  orbit  towards  the  lachrymal  gland.  The  cyst  enlarges 
when  the  patient  weeps.  Dacryops  may  arise  in  two  ways — ■ 
either  as  a  consequence  of  wound  or  abscess  of  the  lid,  or  as 
a  congenital  defect.  As  a  rule,  they  are  of  traumatic  origin. 
The  condition  is  one  of  extreme  rarity. 

Hulke,|  in  an  interesting  paper  on  this  subject,  states 
his  belief  that  these  cysts  were  first  accurately  described  by 


*  The  American  Journal  of  the  Med.  Sciences,  1885,  vol.  xc,  p.  18.  Newton, 
Pitt,  and  Jacobson  (Med.-Chir.  Trans.,  vol.  Ixxiv.,  455),  give  a  good  list  of 
references. 

t  Trans.  Obstet.  Soc,  vol.  xxxi.  311.  See  also  Bramann,  Arch,  fur  Klin. 
Chir.  (von  Langenbeek),  bd.  xxxv.,  s.  201 ;  Mendes  de  Leon,  Am.  Journal  of 
Obstet.,  vol.  xxiv.,  p.  168 ;  Fetherston,  Australian  Med.  Journal,  1890,  p.  475. 

X  E.  Lend.  Opbtb.  Hosp.  Reports,  vol.  i.,  p.  285. 


430  GYSTH. 

Dr.  J.  A.  Schmidt  in  1803,  and  that  Beer  (1817)  mentions 
that  he  had  seen  six  cases  of  this  kind,  which  he  describes 
under  the  name  "  dacryops"  which  Schmidt  had  appHed 
to  them. 

When  these  cysts  are  opened  through  the  skin  a  fistula  is 
sure  to  be  the  resuhj.  The  same  thing  often  happens  when 
the  cysts  have  a  traumatic  origin.  The  condition  is  then 
termed  dacryops  fistulosus. 


431 


CHAPTEE    XL  y  II  I. 

PSEUDO-CYSTS — DIVERTICULA   AND    BURS^. 

The  term  diverticulum  is  used  to  denote  hernia  or  protru- 
sion of  the  lining  membrane  of  a  cavity  through  a  defective 
spot  in  its  walls.  Such  protrusions  occur  in  connection  with 
the  oesophagus  and  intestines  ;  the  bladder  ;  the  trachea ;  also 
in  relation  with  joints  and  tendon-sheaths  forming  synovial 
cysts  and  ganglia;  and  in  blood-vessels  forming  sacculated 
aneurysms  and  varices. 

Intestinal  Diverticula. — These  are  hernial  protrusions  of 
the  mucous  membrane  of  the  bowel  through  interspaces  in 
the  muscular  coat.  Structurally  they  consist  of  mucous 
membrane  with  a  covering  of  peritoneum.  Sometimes  a  few 
strands  of  muscle  fibre  can  be  detected  stretched  across  the 
pouch. 

Frequently  diverticula  occur  in  multiples;  as  many  as 
two  hundred  have  been  found  in  one  case.  These  pouches 
occur  in  all  parts  of  the  intestine,  but  are  most  frequent  in 
the  colon,  and  especially  about  the  sigmoid  flexure.  In  the 
small  intestine  they  usually  occur  along  the  line  of  the  attach- 
ment of  the  mesentery.  In  the  colon  they  are  found  about 
the  attachment  of  the  appendices  epiploicse,  and  may  even 
project  into  them. 

In  dimensions  diverticula  vary  greatly — some  are  as  small 
as  peas,  others  as  large  as  oranges.  When  the  pouches 
are  numerous,  as  a  rule,  they  are  small ;  when  few  in  number, 
or  solitary,  they  may  be  large.  Intestinal  diverticula  are 
common  in  old  persons,  but  they  rarely  lead  to  serious 
consequences. 

Some  writers  describe  diverticula  of  the  intestines  as  con- 
sisting of  two  varieties,  true  and  false.  According  to  this 
arrangement  a  persistent  vitello-intestinal  duct  would  be 
called  a  true  diverticulum.     {See  page  389.) 

Vesical  Diverticula. — Hernial  protrusions  of  the  mucous 
membrane  of  the  bladder  between  the  fasciculi  of  the  muscular 
coat  are  of  frequent  occurrence.     The  cause  of  the  protrusion 


432  FSK  UIJO-  (J  YH  TH. 

is  impediment  to  the  free  flow  of  urine ;  the  ol^struction  muy 
be  seated  in  the  urethra  or  at  the  neck  of  the  bladder. 
Under  such  conditions  there  may  be  several  diverticula ;  the 
^bladder  is  then  said  to  be  sacculated.  Sometimes  there  is 
only  one  saccule,  and  this  may  attain  a  large  size.  Vesical 
diverticula  usually  communicate  with  the  cavity  of  the 
bladder  by  large  orifices.  A  sacculus  extending  into  the 
suspensory  ligament  of  the  bladder  must  not  be  confounded 
with  a  urachus  cyst. 

Sacculated  bladders,  apart  from  the  cause  that  produces 
the  saccules,  do  not  often  give  rise  to  trouble.  Calculi  are 
sometimes  found  within  them,  and  in  cases  where  the  outflow 
of  urine  is  seriously  obstructed  the  walls  of  a  sacculus  will 
sometimes  yield,  and  allow  the  urine  to  extravasate  into  the 
surrounding  loose  connective  tissue.* 

As  impediments  to  the  free  escape  of  urine  from  the 
bladder  occur  more  frequently  in  men  than  in  women,  it 
naturally  follows  that  sacculated  bladders  are  most  common 
in  men.  Nevertheless,  vesical  diverticula  of  large  size  are 
occasionally  found  in  women,  and  in  exceptional  cases  have 
caused  death. f 

Pharyngeal  Diverticula  {Pharyngoceles). — Localised  dila- 
tations of  the  pharynx  are  of  three  kinds  : — 

1.  Abnormal  persistence  and  distension  of  certain  pouches 

which,  as  a  rule,  exist  in  the  embryo  only — e.g.,  the 
pouch  of  Rathke  and  the  branchial  clefts.  J 

2.  Pouching  of  the  pharyngeal  wall  at  its  junction  with 

the  oesophagus. 

3.  Protrusions  (hernite)  of  the  mucous  membrane  lining 

Rosenmliller's  fossa. 

The  cysts  of  the  first  kind  have  been  already  discussed 
in  chapter  xxxv.  Dilatations  of  the  pouch  of  Rathke  are 
considered  at  page  317,  branchial  cysts  at  page  327,  and  the 
curious  guttural  pouches  of  the  horse  at  page  387. 

*  For  an  interesting  account  of  the  relation  of  diverticula  of  the  hladder  to 
extravasation  of  urine  cf.  Lane,  Guy's  Hospital  Reports,  1885. 

t  Halo  White,  Trans.  Path.  Soc,  vol.  xxxiv.  146. 

+  Pouches  of  the  naso-pharynx  have  heen  described  in  detail  by  Kostanecki, 
Virchow's  "  Archiv,"  bd.  cxvii.,  108. 


BIVEBTWULA. 


433 


Pharyngoceles. — In  order  to  appreciate  the  nature  of  at 
least  one  form  of  pharyngeal  pouch  it  will  be  necessary  to 
take  into  consideration  an  interesting  congenital  defect  to 
which  the  pharynx  is  liable. 

It  occasionally  happens  that  children  are  born  with  what 
is  known  as  an  imperforate  pharynx,  that  is,  instead  of  the 
pharynx    and   oesophagus   forming   a   continuous    tube,    the 
pharynx  terminates  as  a  cul- 
de-sac  near  the  level  of  the 
cricoid  cartilage. 

In  such  cases  the  upper 
end  of  the  oesophagus  termi- 
nates by  opening  into  the 
trachea  through  its  posterior 
wall.  The  situation  of  the  oeso- 
phago-tracheal  fistula  varies 
in  different  specimens  ;  some- 
times it  is  as  high  as  the  third 
tracheal  semi-ring,  or  it  may 
be  as  low  as  the  bifurcation 
of  the  trachea,  and  in  at  least 
one  case  it  opened  into  the 
left  bronchus.  In  most  ex- 
amples of  imperforate  pharynx 
the  oesophagus  is  connected 
with  the  lower  end  of  the 
pharynx  by  a  fibrous  band, 
which  indicates  that  the  two 
structures  were  originally  continuous,  but  that  their  continuity 
has  been  disturbed  by  secondary  changes.     (Fig.  220.) 

The  constant  association  of  an  oesophago-tracheal  fistula 
and  imperforate  pharynx  indicates  some  relation  between  the 
two  conditions.  The  explanation  which  at  once  suggests 
itself  is,  that  it  may  be  due  to  some  influence  exercised  by 
the  pulmonary  diverticulum  which  leaves  that  portion  of  the 
embryonic  fore-gut  ultimately  represented  by  the  oesophagus.* 
{See  also  Imperforate  Ileum,  page  393.) 


J _Apertui'e  by 

wliieli  the. 
oesophagus 
communicates 
with  the  trachea. 


Fig.  220.— Iiuiierforate 
pharynx. 


*  This  subject  is  handled  with  remarkable  acumen  by  Shattock, 
Path.  Soc,  vol.  xli.,  p.  87. 
C  C 


Trans. 


434 


PSEUDO-CYSTS'. 


Ill  some  cases  the  pharynx  instead  of  ending  blindly  may 
be  abnormally  narrow  at  its  junction  with  the  cesophagus, 
and  a  valve  may  exist.  An  imperforate  pharynx  is  incom- 
patible with  life,  but  the  oesophagus  may  be  considerably 
stenosed  and  cause  no  inconvenience  in  deglutition  (Fig.  221). 

It  is  necessary  to  describe  con- 
genital imperfections  at  the  junction 
of  the  pharynx  and  cesophagus,  be- 
cause it  is  at  this  point  that  pouches 
are  apt  to  form.  A  typical  example 
of  a  pharyngeal  pouch,  or  pharyngo- 
cele,  is  shown  in  Fig.  222.  The  case 
is  very  carefully  described  by  Worth- 
ington*  The  parts  were  obtained 
from  a  man  sixty-nine  years  of  age. 
There  was  a  stricture  of  the  oeso- 
phagus at  the  level  of  the  cricoid 
cartilage  that  would  admit  merely 
a  urethral  bougie.  This  obstruction 
ultimately  led  to  the  death  of  the 
patient.  He  could  swallow  food  and 
retain  it  for  a  time ;  it  would  then 
regurgitate.  At  the  post-mortem  dis- 
section the  pouch  was  detected  ;  it 
was  in  shape  like  the  finger  of  a 
glove,  and  had  a  depth  of  9  cm.  and 
a  circumference  of  6  cm.  The  mu- 
cous membrane  at  the  seat  of  the 
stricture  was  quite  healthy.  About 
two-thirds  of  the  pouch  were  covered  with  muscle  derived 
from  the  inferior  constrictor. 

An  examination  of  pharyngeal  pouches  such  as  exist  in 
museums  would  lead  the  observer  to  believe  that  the  orifice 
of  communication  between  the  pharynx  and  the  pouch  was 
circular ;  but  there  is  good  reason  to  believe  that  it  assumes 
a  slit-like  form  even  when  the  pouch  is  full  of  food. 

So  far  as  our  knowledge  at  present  extends  in  regard  to 
this  variety  of  pharyngocele,  it  would  appear  that  they  arise 
in  all  probability  as  congenital  effects,  but  it  is  important  to 

*  Med.  Chir.  Trans.,  vol.  xxx.  199. 


Fig.  221. — Septate  pharynx. 


DIVEBTIGULA. 


435 


remember  that  the  pouch  rarely  causes  inconvenience  until 
late  in  life.  Thus  Ludlow's'^  patient  was  sixty ;  Worthington's, 
sixty-nine  ;  Chavasse's,t  forty-nine  ;  and  Butlin's,J  forty-seven. 
It  is  necessary  to  point  out  that  a  pharyngocele  of  the 
character  represented  in  Fig.  222  arises  in  a  different  manner 
to  that  depicted  in  Fig.  155 ;  the  latter  is  probably  due  to  a 
persistent  branchial  cleft.  It  is  also  quite  certain  that  any 
attempt  to  dissect  out  a  lateral 
sac  of  this  kind  would  require 
more  skill  than  such  a  pouch  as 
that  shown  in  Fig.  222. 

Treatment. —  Pharyngoceles 
are  likely  to  be  much  more  care- 
fully studied  in  the  future  than 
they  have  been  in  the  past,  for 
the  condition  has  on  more  than 
one  occasion  been  correctly  diag- 
nosed, and  the  pouch  removed 
through  an  incision  in  the  neck, 
and  its  slit-like  orifice  of  com- 
munication with  the  pharynx 
occluded  by  sutures,  a  manceuvre 
that  has  been  followed  with 
complete  success  in  the  hands  of 
Bergmann§  and  Butlin. 

(Esophageal  Diverticula. — 
Hernial  protrusions  of  the  mu- 
cous membrane  of  the  oesopha- 
gus through  the  muscular  coat 
are  not  common.  They  vary  greatly  in  size.  Some  are  no 
larger  than  cherries,  others  may  attain  the  size  of  a  closed 
fist.  Diverticula  arise  in  any  part  of  the  oesophagus ;  nothing 
is  known  as  to  their  cause. 

Tracheal  Diverticula. — These  are  small  hernial  protru- 
sions of  the  mucous  membrane  of  the  trachea ;  they  are 
uncommon  and  invariably  occur  near   the  junction  of  the 


Fig.  222,— Pharyngeal  diverticulum. 
{After  Worthington.) 


*  "Medical  Observations  and  Inquiries,"  1767,  vol.  iii.,  p.  85,  pi.  v. 

t  Trans.  Path.  Soc,  xlii.  82. 

J  Med. -Chir.  Trans.,  vol.  Ixxvi. 

§  Langenbeck's  "  Archiv,"  bd.  xliii. ,  s.  1. 


436 


PSEUDO-CYSTS. 


tracliealis  muscle  with  the  cormia  of  the  semi-rings  of  the 
trachea.  Rokitansky  regarded  thorn  as  dependent  on  chronic 
catarrh  of  the  trachea.  Gruber,  on  the  other  hand,  was  of 
opinion  that  they  are  retention  cysts  of  the  glands  in  the 
tracheal  mucous  membrane ;  they  are  of  little  clinical  interest. 


3/5<s«j;,i'n.i) 


i)^-      septum. 


Wall  of  poucli. 


Wall  of  pencil 


Fig.  223. — Tracheal  opening  and  pouch  of  an  emu.    The  pouch  is  cut  so  as  to  expose  its 
interior.    The  surrounding  feathers  are  cut  short.     (After  Miirie.) 


The  Tracheal  Diverticulum  of  the  Emu. — The  emu  [Dromceus 
novce-hollandice)  is  normally  provided  with  a  tracheal  diverticulum  of  great 
interest.  In  this  bird  there  is  a  natural  defect  in  the  front  of  the  trachea, 
at  a  spot  varying  between  the  fiftieth  and  sixty-fifth  ring.  The  deficiency 
may  involve  six  or  more  rings.  In  the  emu  chick  the  defect  is  scarcely 
noticeable,  and  the  extremities  of  the  rings  are  almost  in  contact.  As  the 
bird  grows  the  tracheal  mucous  membrane  becomes  slowly  herniated 
through  the  opening  until  it  forms  a  huge  sac  between  the  skin  of  the  neck 
and  the  trachea.      The  cyst-wall  is  composed  of  connective  tissue  with 


BIVEBTIGULA.  437 

scattered  bundles  of  striated  muscle  fibre  ;  its  mucous  liuiug  is  directly- 
continuous  with  that  of  the  windpipe,  and  is  dotted  with  the  orifices  of 
glands.     (Fig.  223.) 

The  adult  emu  inflates  this  sac  when  it  produces  the  peculiar  booming 
sound  which  resembles  the  noise  made  by  blowing  across  the  mouth  of  a 
large  bottle. 

This  large  tracheal  sac  may  inflame  and  become  distended  with  mucus. 
In  a  specimen  which  I  secured  and  forwarded  for  preservation  in  the 
museum  of  the  Royal  College  of  Surgeons,  London,  the  sac  contained 
two  plots  of  mucus.  The  bird  was  unfortunately  di-owned  in  this  fluid, 
for  while  I  was  making  an  attempt  to  evacuate  the  contents  of  the  sac  the 
fluid  entered  the  opening  in  the  trachea  and  suffocated  it. 

Murie*  has  written  an  excellent  account  of  the  anatomy  of  the  trachea 
of  the  emu.  I  can  confirm  his  observations,  having  enjoyed  the  oppor- 
tunities of  dissecting  the  adidt  emu  and  the  emu  chick.  Concerning  tlie 
function  of  this  pouch  nothing  is  known. 

Synovial  Cysts. — Cysts  containing  synovia  arise  in  three 
ways : — 

(1)  Hernial    protrusions   of   the   synovial   membranes   of 
joints. 

(2)  BurssE!  in  the  immediate  neighbourhood  of  joints. 

(3)  Hernial     protrusions     of    the    synovial     sheaths     of 
tendons. 

Synovial  cysts  arise  in  connection  with  the  hip,  knee, 
ankle,  shoulder,  elbow,  and  wrist  joints.  They  have  been 
most  carefully  studied  in  connection  with  the  knee  joint. 
The  cysts  form  swellings,  in  some  cases  as  large  as  an  orange, 
situated  near  the  knee  joint,  usually  in  close  relation  with  the 
tendons  of  the  semi-membranosus,  biceps,  or  gastrocnemius 
muscles.  Occasionally  the  cyst  will  be  situated  in  the  calf  on 
the  inner  side,  sometimes  as  much  as  8  cm.  below  the  knee. 
When  the  swelling  is  situated  near  the  joint,  pressure  will 
cause  it  to  disappear,  the  synovia  it  contains  passing  into  the 
general  cavity  of  the  joint.  When  the  cyst  is  situated  at  a 
distance  from  the  joint,  pressure  upon  it  has  no  effect  in 
diminishing  its  size,  because  in  many  cases  the  communication 
between  the  cyst  and  the  joint  cavity  is  by  a  very  narrow, 
almost  capillary  channel. 

The  cysts  arise  usually  in  connection  with  joints  which 
are  chronically  diseased  and  seem  to  be  common  in  tubercular 
joints.     It   is   believed   by  those   who   have  devoted  special 

*  Proc.  Zool.  Soc,  1867,  p.  405. 


438 


PSEUDO-CYSTS. 


attention  to  tliese  cysts  that  when  the  joints  become  dis- 
tended with  synovia,  the  internal  pressure  causes  the  synovial 
membrane  to  protrude  through  weak  spots  in  the  capsule,  the 
diverticula  making  their  way  along  the  intermuscular  planes. 


,,     Opening  of  bursa  into  the  joint. 


Remains  of  a  previous  cyst. 


Fig.  224.— Bursa  under  the  semi-uiembranosus  tendon  communicating  with  the  knee-.ioint.  A 
cyst  had  been  incised  and  drained  sixteen  months  previously.  Its  partially-obliterated 
channel  persists.     {D'Arcy  Power.) 

This  mode  of  origin  is  on  all-fours  with  that  which  obtains  in 
the  case  of  sacculated  bladders. 

It  is  also  certain,  for  it  has  been  demonstrated  by  dissection, 
that  some  synovial  cysts  are  due  to  bursse  normally  existing 
under    the    adjacent    tendons,    becoming    abnormally   large 


DIVERTICULA.  439 

and  communicating  with  the  joint  cavity  in  consequence  of 
absorption  of  the  contiguous  parts  of  the  wall  by  pressure. 
(Fig.  224.)  This  seems  to  happen  most  frequently  in  the  case 
of  the  bursa  under  the  semi-membranosus.  It  does  not 
necessarily  follow  because  an  individual  has  a  synovial  cyst 
near  the  knee  that  the  joint  is  diseased;  attendance  in  an 
out-patient  room  will  show  that  many  synovial  cysts  slowly 
disappear  without  treatment.  This  is  important  to  bear 
in  mind,  for  interference  with  these  cysts  is,  as  a  rule, 
-needless  and  often  productive  of  much  harm.  Aspira- 
tion, injection  of  iodine,  and  the  insertions  of  setons  may  lead 
to  suppuration  and  destruction  of  the  joint,  with  which  the 
cyst  is  connected.  Mr.  Morrant  Baker,  who  first  drew  special 
attention  to  these  synovial  diverticula,  states  that  when  they 
arise  in  connection  with  the  knee,  the  cyst  will  project  in  the 
popliteal  space,  the  upper  part  of  the  calf,  or  on  the  inner  side 
of  the  calf  as  much  as  10  cm.  below  the  head  of  the  tibia. 

In  the  case  of  the  shoulder  the  cyst  projects  in  front  of 
the  joint  a  little  below  the  clavicle,  or  in  the  upper  third 
of  the  arm  in  the  course  of  the  long  tendon  of  the 
biceps. 

In  the  case  of  the  elbow,  the  cyst  projects  on  the  inner  side 
of  the  arm  above  the  condyle.  I  have  seen  a  cyst  of  this  kind 
as  high  as  the  insertion  of  the  coraco-brachialis,  connected 
with  the  elbow  joint  by  a  tubular  process  of  the  diameter  of 
the  anterior  interosseous  artery.  When  they  arise  from  the 
carpal  joints,  the  cysts  project  on  the  back  or  front  of  the 
wrist.  (See  under  Ganglion.)  When  connected  with  the  hip- 
joint,  the  cyst  forms  a  swelling  in  Scarpa's  space,  and  in  the 
case  of  the  ankle  the  bulging  is  most  marked  in  front  and  to 
the  outer  side  of  the  joint. 

The  fluid  contained  in  synovial  cysts  is  in  most  cases 
identical  with  synovia.  When  the  joint  is  the  seat  of  tuber- 
cular disease  the  fluid  in  the  cyst  will  contain  pus  cells,  and 
occasionally  it  is  true  pus ;  when  the  skin  over  these  swellings 
is  red  and  glossy  they  have  been  mistaken  for  simple  abscesses 
and  incised. 

Rarely  the  cyst  contains  melon-seed  bodies.  In  one  case 
Mr.  Bentlif  opened  a  cyst  of  this  kind  connected  with  the 
shoulder  and  removed  two  thousand  of  these  bodies.     Most  of 


440  PSE  UD  0-  G  YS  TS. 

them  were  of  the  shape  and  size  of  apple-pips,  and  like  pips, 
had  small  stalks  or  tails. 

Ganglion. — ^A  ganglion  is  a  cyst  formed  by  the  hernial 
protrusion  of  the  synovial  lining  of  a  tendon  sheath.  There 
are  two  species — simple  and  compound. 

A  simple  ganglion  is  seen  in  its  most  typical  condition  on 
the  back  of  the  carpus,  where  it  forms  a  rounded,  sessile, 
elastic  swelling  which  becomes  tense  when  the  wrist  is  flexed, 
and  partially,  or  wholly,  disappears  when  the  wrist  is  extended. 
Many  of  these  swellings,  which  are  entered  in  clinical  records 
as  ganglions  (or  ganglia),  are  not  all  connected  with  tendon 
sheaths.  I  have  satisfied  myself  by  careful  dissections  that 
many  of  them  are  diverticula  from  the  carpal  joints,  and  in 
some  instances  they  arise  from  the  inferior  radio-ulnar  joint. 
During  life  it  is  difficult  to  distinguish  between  a  hernia  of  the 
sheath  of  a  tendon  or  a  diverticulum  from  a  carpal  joint.  As 
in  the  case  of  the  larger  joints,  synovial  cysts  arising  from  the 
carpus  are  occasionally  associated  with  tubercular  arthritis. 

Ganglia  are  sometimes  met  with  on  the  fingers  in  connec- 
tion with  the  sheaths  of  the  long  flexors,  and  on  the  dorsum  of 
the  foot,  as  well  as  on  the  outer  side  of  the  ankle,  in  relation 
with  the  tendons  of  the  peroneus  longus  and  brevis.  The 
fluid  in  a  simple  ganglion  is  clear,  transparent  and  viscid,  and 
resembles  apple  jelly. 

The  compound  ganglion  is  a  much  more  serious  condition. 
It  occurs  mainly  in  connection  with  the  flexor  and  extensor 
tendons  at  the  wrist ;  it  also  occurs  occasionally  on  the  tendons 
of  the  peronei  muscles,  where  they  lie  in  relation  with  the 
calcaneum. 

A  compound  ganglion  at  the  wrist  assumes  an  irregular 
shape  and  extends  for  a  variable  distance  up  the  forearm ;  it 
also  sends  a  prolongation  under  the  annular  ligament  to  appear 
in  the  palm,  when  it  arises  in  connection  with  the  flexor 
tendons;  a  similar  extension  under  the  posterior  annular 
ligaments  is  usually  noticed  when  a  ganglion  is  connected 
with  the  extensor  tendons.  A  compound  ganglion 'is  usually 
soft  and  elastic,  and  imparts  a  crepitant  sensation  to  the 
examininsf  fingers  when  the  tendons  are  set  in  action.  This 
crepitant  sensation  is  due  to  the  presence  in  the  ganglion 
of  small  bodies  familiarly  known  as  melon-seed  bodies  from 


BUESM  441 

tlieir  shape  and  consistence ;  they  are  sometmies  present 
in  enormous  numbers.  There  is  much  difference  of  opinion 
as  to  the  source  of  these  bodies.  I  have  seen  them  hanging 
from  the  inner  wall  of  the  ganglion.  An  examination  of  many 
of  the  loose  bodies  will  show  that  they  have  slender  stalks: 
these  appear  more  clearly  when  they  are  floated  in  water. 
Bodies  identical  in  structure  are  met  Avith  in  synovial  diver- 
ticula and  even  in  bursal  sacs,  particularly  the  prepatellar 
bursa. 

Treatment. — A  simple  ganglion,  such  as  is  so  common  on 
the  back  of  the  wrist,  is  in  a  general  way  successfully  treated 
by  bursting  it  subcutaneously  by  the  direct  pressure  of  the 
thumb,  and  then  applying  a  graduated  compress  for  a  few 
days.  When  the  wall  is  so  thick  that  it  will  not  rupture  the 
swelling  may  be  punctured  with  a  very  narrow  scalpel ;  this 
allows  the  mucoid  contents  to  escape,  and  the  application  of 
a  firm  compress  for  a  few  days  will  obliterate  the  sac. 

Compound  ganglia  require  more  radical  treatment.  Many 
have  been  successfully  treated  by  incising  the  sac,  squeezing 
out  the  contents — particularly  any  loose  bodies  the  sac  may 
contain — and  detaching  those  which  may  happen  to  hang 
from  the  wall  by  means  of  a  scoop.  The  sac  should  be  care- 
fully drained.  Now  and  then  severe  complications  have 
followed  this  method  of  treatment,  and  it  has  been  necessary 
to  amputate  through  the  forearm. 

In  some  cases  the  ganglion  has  been  successfully  dissected 
out  as  if  it  were  a  tumour,  and  it  would  appear  that  the 
patient  runs  less  risk  from  this  mode  of  treatment  than  by 
the  common  practice  of  incision  and  drainage. 

It  is  well  to  bear  in  mind  that  some  of  these  ganglia  are 
associated  with  the  early  stages  of  tubercular  disease  of  the 
wrist  joint,  and  a  few  are  undoubtedly  due  to  tubercular 
infection  of  the  tendon  sheaths. 

BURSJE. 

On  many  parts  of  our  bodies  where  muscles  and  tendons 
glide  over  osseous  surfaces,  or  in  situations  where  skin  lies  in 
close  contact  with  bony  prominences,  membranous  sacs  occur 
filled  with  glairy  fluids ;  such  sacs  are  known  as  bursse. 
Structurally  a  bursa  consists  of  a  thin-walled  sac  filled  with 


442  FSEIW0-0Y8TS. 

glairy  fluid.     The  inner  wall  of  the  cyst  is  quite  smooth  and, 
as  a  rule,  devoid  of  epithelium. 

In  certain  situations,  such  as  the  anterior  surface  of  the 
patella  and  the  posterior  surface  of  the  olecranon,  a  bursa  is 
normally  present.  Bursal  sacs  may  form  in  any  part  of  the 
subcutaneous  tissues  when  the  overlying  skin  is  submitted  to 
unusual  intermittent  pressure,  as  in  talipes  when  the  patient 
walks  on  the  dorsum  or  side  of  the  foot ;  beneath  corns  ;  and 
at  the  metatarso-phalangeal  joint  in  the  condition  termed 
bunion.  Such  are  called  adventitious  bursse.  When  bursas 
arise  in  connection  with  tendons,  they  are  spoken  of  as 
subtendinous  bursae,  and  they  often  communicate  with  the 
sheath  of  the  tendon,  and  even  with  an  adjacent  joint.  The 
large  bursa  so  constantly  present  at  the  insertion  of  the 
semi-membranosus  often  has  a  direct  communication  with 
the  joint  (Fig.  224). 

The  origin  of  bursal  sacs  has  been  explained  in  the 
following  manner : — 

-  When  the  skin  moves  over  joints,  or  passes  over  hard 
prominences,  the  intermediate  connective  tissue  becomes  torn 
or  ruptured,  thereby  leading  to  the  formation  of  spaces  in 
which  fluid  collects.  The  boundary  walls  are  at  first  irregular, 
and  formed  by  adjacent  connective  tissue.  Finally  this  becomes 
smooth  and  forms  the  sac-wall. 

Bursge  may  arise  during  intra-uterine  life  when  the  foetus 
is  submitted  to  abnormal  pressure.  Many  remarkable  in- 
stances of  this  have  been  recorded,  especially  in  association 
with  talipes. 

Most  subcutaneous  and  many  subtendinous  bursas  arise 
after  birth.  When  a  subcutaneous  bursa  attains  an  abnormal 
size  it  is  invariably  due  to  unusual  pressure  associated 
with  particular  occupations.  For  instance,  too  much  kneeling 
on  hard  material,  whether  in  housemaids,  devout  persons, 
or  carpet-layers,  produces  the  familiar  prepatellar  bursa ; 
repeated  blows  on  the  elbow  produce  miner's  elbow;  from 
carrying  weights  on  the  shoulder  porters  are  liable  to  get 
a  bursa  over  the  acromial  end  of  the  clavicle ;  tailors  from 
their  cross-legged  habit  of  sitting  are  sometimes  troubled 
with  one  over  the  external  malleolus ;  whilst  weavers  and 
lightermen  from  prolonged  sitting  on  hard  seats  suffer  from 


BUnSM.  443 

burst©  over  their  ischial  tuberosities ;  soldiers  when  sleeping 
too  frequently  on  the  hard  floor  of  the  guard-room  get  them 
over  their  greater  trochanters  ;  the  pressure  of  ill-fitting  boots 
develops  a  bursa  over  the  enlarged  head  of  the  metatarsal 
bone  of  the  hallux ;  when  associated  with  partial  dislocation 
of  the  first  phalanx  it  is  known  as  a  bunion,  and  bursse  are 
quite  common  on  the  ends  of  amputation  stumps.  Clement 
Lucas*  has  described  as  the  needlewoman's  bursa  a  cyst 
that  formed  on  the  palmar  surface  of  the  terminal  phalanx 
of  the  middle  finger  in  an  old  seamstress. 

A  bursa  is  often  present  between  the  body  of  the  hyoid 
bone  and  the  thyro-hyoid  membrane ;  sometimes  it  is  very 
large  and  may  attain  the  dimension  of  a  fist. 

Bursa3  are  liable  to  inflame,  a  process  that  may  lead  to 
suppuration,  or  stop  short  of  that  condition  and  become 
chronic  or  recurrent  and  lead  to  secondary  changes  in  the 
walls  of  the  sac,  so  that  its  cavity  becomes  almost  obliterated. 
Chronically-inflamed  burste  sometimes  attain  the  size  of  fists, 
especially  the  prepatellar  and  ischial  varieties. 

Jephson,  in  his  interesting  account  of  "  Emin  Pasha  and 
the  Rebellion  at  the  Equator,"  relates  that  the  women  and 
many  men  of  the  Bari  tribe  whom  he  saw  working  in  the 
fields,  had  enlarged  prepatellar  bursse  (housemaid's  knee)  due 
to  kneelino-  whilst  at  work  and  to  the  fact  that  the  entrances 
to  the  huts  were  so  low  that  it  was  necessary  to  enter  on  the 
hands  and  knees. 

Treatment. — An  inflamed  bursa  demands  rest  and  the 
local  treatment  usually  employed  for  inflamed  parts.  When 
the  bursa  is  distended  with  fluid,  it  is  the  custom  to  apply 
a  plaster  of  mercury  and  ammoniacum  over  the  swelling 
and  fix  it  firmly  with  a  bandage.  It  is  probable  that 
the  firm  compression  is  the  chief  agent  in  promoting  the 
absorption  of  the  fluid.  In  some  cases  the  swelling  subsides 
spontaneously  and  this  probably  explains  the  supposed 
efiicacy  of  the  application  of  tincture  of  iodine. 

When  bursse  are  repeatedly  irritated,  the  walls  become  so 
thick  that  it  is  necessary  to  excise  the  tumour.  When 
the   bursa   is   situated   over    the    patella,   malleolus,   ischial 

*  Guy's  Hospital  Eeports,  vol.  xliii.  143. 


444  PSEUDO-CYSTS. 

tuberosity,  or  trochanter  its  removal  is  a  very  simple  pro- 
ceeding. 

When  a  bunion  inflames  and  suppurates  it  may  involve 
the  underlying  metatarso-phalangeal  joint.  Many  of  these 
cases,  especially  in  elderly  individuals,  demand  amputation 
of  the  toe.  When  it  is  necessary  to  carry  out  this  measure, 
I  find  it  much  more  satisfactory  to  remove  the  metatarsal 
bone  as  well  as  the  toe. 

When  the  bursa  between  the  body  of  the  hyoid  bone  and 
the  thyro-hyoid  membrane  is  very  large  it  should  be  incised 
and  drained.  Care  is  necessary  to  avoid  confounding  an 
enlarged  thyro-hyoid  bursa  with  a  cyst  of  an  accessory 
thyroid  gland  and  vice  versa. 


445 


CHAPTER  XLIX. 

NEURAL    CYSTS. 


Under  this  heading  it  is  proposed  to  consider  a  number  of 
conditions,  some  of  which,  hke  hydrocephahis  and  one  variety 
of  spina  bifida,  should  be  described  in  the  genus,  tubulo-cysts. 


Fig.  225.— Hydrocephalic  skvill,  from  an  infant.     {Museum,  Middlesex  Hospital.) 

Other  varieties  of  spina  bifida  should  be  discussed  with  diver- 
ticula. On  the  whole  it  is  more  convenient  to  consider  them 
collectively  as  a  genus — neural  cysts. 

Hydrocephalus. — This  term  is  applied  to  the  head  when 
abnormally  enlarged  in  consequence  of  excessive  accumulation 
of  fluid  in  the  ventricles  of  the  brain.  By  far  the  larger 
majority  of  cases  are  congenital,  or  commence  in  the  early 
months  of  infancy.  Occasionally  it  will  arise  at  a  later  period 
of  life,  when  the  fontanelles  are  obliterated ;  expansion  of  the 
skull  is  then  impossible.  Hydrocephalus  very  frequently 
accompanies  spina  bifida.  Very  many  hydrocephalic  foetuses 
die  during  delivery,  the  large  size  of  the  head  hindering  its 
successful  transit  through  the  maternal  passages.     In  some 


446 


PSEUDO-CYSTS. 


cases  the  head  ruptures  in  consequence  of  the  pressure  to 
which  it  is  subjected,  or  is  intentionally  perforated.  In  most 
cases  of  hydrocephalus  which  survive  delivery,  distension  is 
only  slight  at  birth. 

The  frequency  with  which  hydrocephalus  and  hydramnios 
co-exist  would  indicate  that  the  association  is  something  more 
than  mere  coincidence.     Statistics  respecting  the  frequency  of 


Fig.  226. — Hydrocephalic  skull,  showing  Woi'iniau  bones.     (Museum,  Middlesex  Hospital.) 


hydrocephalus  drawn  from  living  children  are  untrustworthy, 
as  pre-natal  hydrocephalus  is  very  fatal. 

In  typical  cases  of  hydrocephalus  attention  is  arrested  by 
the  large  size  of  the  cranium  and  the  smallness  of  the  face. 
This  is  due  to  the  slow  accumulation  of  fluid  within  the 
cerebral  ventricles,  distending  them  and  causing  wide  separa- 
tion of  the  cranial  bones,  whilst  the  bones  of  the  face  retain 
their  natural  proportions.  The  two  halves  of  the  frontal  bone 
are  separated  from  each  other ;  the  spaces  between  the  parietal 
bones,  and  between  these  and  the  occipital,  are  far  wider  than 
usual.     (Fig.  225.)     Indeed,  the  bones  of  the  cranial  vault  are 


NEURAL   GTSTS.  447 

SO  separated  from  each  other,  whilst  those  of  the  base  retain 
their  usual  juxtaposition,  that  the  bones  of  a  hydrocephalic 
skull  were  compared  by  Trousseau*  to  the  petals  of  an 
opening  flower. 

The  head  may  become  so  large  as  to  attain  a  circumference 
of  a  metre,  or  even  a  metre  and  a  half  when  measured  horizon- 
tally— that  is,  from  the  superciliary  ridges  to  the  occiput.     The 


Fig.  227.— Sagittal  section  of  a  liydrocephalic  skull  from  a  child,  -with  tlie  brain  in  situ.  Tlie 
head  of  the  arrow  is  in  the  fourth  and  its  feathers  in  tlie  third  ventricle.  Tlie  infun- 
dibulum  is  widely  dilated.     [Miis&um,  Middlesex  Hospitcd.) 

bones  are  excessively  thin,  and  consist  of  a  single  table.  The 
vault  presents  large  membranous  spaces  irregularly  dotted 
with  ossific  deposits.  The  sutures  in  relation  with  the 
parietal  bones  are  occupied  with  Wormian  bones ;  as  many  as 
two  hundred  have  been  counted  in  one  skull.  (Fig.  226.)  In 
hydrocephalics  who  attain  adult  life  the  skull  may  become 
completely  covered  in  with  bone. 

*  CUnique  Mklicale,  torn,  ii.,  p.  321. 


448  I'SE  UDO-  (J  YS  TS. 

The  brain  presents  great  changes.  The  Literal  ventricles 
are  widely  distended,  and  the  crura  cerebri,  corpora  striata, 
optic  thalami,  and  other  structures  in  the  base  of  the  brain 
are  flattened.  The  cerebral  hemispheres  form  thin  boundaries 
to  the  ventricles,  often  less  than  10  mm.  in  thickness ;  the 
convolutions  become  obliterated.  In  nearly  all  the  specimens 
the  distension  is  limited  to  the  lateral  and  third  ventricles : 
occasionally  the  fourth  ventricle  is  also  distended.  (Fig.  227.) 
In  some  specimens  each  lateral  ventricle  has  been  known  to 
attain  a  length  of  20  cm.  and  to  communicate  Avith  its  fellow 
through  an  opening  the  size  of  an  orange. 

When  the  ventricles  are  very  distended  and  the  skull 
is  proportionally  thin,  a  wave  of  fluctuation  may  be  transmitted 
from  side  to  side.  In  exceptional  cases  the  head  is  trans- 
lucent. 

In  an  account  of  hydrocephalus  it  is  difficult  to  avoid 
reference  to  the  classical  case  of  James  Cardinal,  es23ecially 
as  a  cast  of  his  head  is  to  be  found  in  many  pathological 
museums.     (Fig.  228.) 

James  Cardinal  died  at  the  age  of  twenty-nine  years  in 
Guy's  Hospital  under  the  care  of  Sir  Astley  Cooper,  in  1824. 
He  was  born  at  Coggeshall,  Essex,  in  1795.  At  birth  his 
head  was  very  little  larger  than  natural.  A  fortnight  later 
it  began  to  increase,  and  gradually  grew  until  he  was  five 
years  old ;  it  then  appeared  to  remain  stationary.  He  was 
unable  to  walk  until  six  years  of  age,  but  went  to  school  and 
learned  to  read  and  write.  His  head  was  at  this  period 
translucent  when  placed  between  the  eye  of  the  observer  and 
a  bright  light.  Cardinal  continued  in  tolerable  health  until 
twenty-three  years  of  age,  when  he  began  to  have  fits,  for 
which  he  applied  to  the  hospital.  His  manners  were  childish, 
otherwise  his  mental  faculties  were  well  developed.  Death 
eventually  supervened  from  lung  disease. 

When  the  head  was  examined  the  brain  vv^as  found  lying 
at  the  base  of  the  skull.  Between  the  membranes  there  were 
seven  pints  of  fluid.  The  ventricles  contained  one  pint.  It 
appeared  as  if  the  fluid  had  originally  been  contained  within 
the  ventricles,  but  had  burst  through  an  opening  on  the 
corpus  callosum  and  compressed  the  brain  downwards.  The 
cranium  measured  82-5  cm.  (33")  in  circumference,  and  had  a 


NEURAL    GYST8. 


449 


capacity  of  ten  pints.     The  skeleton  is  contained  in  Guy's 
Hospital  museum. 

The  fluid  in  hydrocephalus  is  identical  with  cerebro-spinal 
fluid.  Occasionally  it  has  been  found  to  contain  albumen. 
This  may  be  attributed  to  inflammation,  and  has  been  observed 
in  those  cases  where  paracentesis  has  been  performed.     The 


Fi?;.  228.— Drawing  from  a  cast  of  the  head  of  James  Cardinal.* 


amount  of  fluid  may  be  very  large.     Six  and  eight,  and  even 
ten  pints  have  been  recorded. 

Little  is  known  as  to  the  cause  of  hydrocephalus.  In  many 
cases  obstruction  to  the  interventricular  communications  has 
been  detected.  Hydrocephalus  is  often  associated  with  spina 
bifida,  and  all  the  passages  in  the  brain  with  the  central  canal 
of  the  cord  have  been  found  dilated.  In  several  cases  in 
which  hydrocephalus  supervened  on  spina  bifida  I  found  the 
central  canal  of  the  cord  normal.  Interference  with  the 
interventricular  passages   will    produce   hydrocephalus.      In 

*  The  cast  from  which  this  drawing  was  taken  appears  to  have  been 
moulded  April  11th,  1822.     Cardinal  was  then  at  St.  Thomas's  Hospital. 


450 


FSEUDO-GYSTS. 


Fig.  229  the  head  of  a  hon-Avhelp  is  shown  in  sagittal  section. 
The  ossified  tentorium  is  abnormally  thick  in  consequence  of 
rickety  changes.  This  had  depressed  the  vermiform  process 
of  the  cerebellum  and  obstructed  the  Sylvian  aqueduct,  lead- 
ing to  distension  of  the  lateral  and  third  ventricles  and  the 
infundibulum. 

The  great  difficulty  encountered  in  investigating  the 
pathology  of  this  condition  arises  from  the  soft  and  diffluent 
nature  of  the  brain  of  hydrocephalic  foetuses,  especially  when 
stillborn.     It  should  also  be  remembered  that  many  grave 


Thickened  tentorium. 


Dilated  mfuudibulum. 


Pig.  229. — Head  of  a  lion's  wlielj)  in  section,  showing  great  dilatation  of  the  cerehral  ventricles 
due  to  obstruction  of  the  interventricular  passages  by  a  thickened  (rickety)  tentorium. 

malformations  of  the  limbs  and  viscera  are  often  associated 
with  hydrocephalus,  and  it  is  well  to  bear  in  mind  the  fre- 
quency with  which  it  is  accompanied  by  hydramnios. 

Hydrocele  of  the  Fourth  Ventricle. — Leading  from  each 
lateral  angle  of  the  fourth  cerebral  ventricle  there  is  a  tubular 
process  encircled  by  a  duplicature  of  the  ligula  termed  the 
cornucopia.  These  passages  or  lateral  recesses  are  traversed 
by  the  choroid  plexuses  of  the  fourth  ventricle,  and  the  re- 
cesses themselves  open  into  the  subarachnoid  space  at  the 
base  of  the  flocculus,  close  beside  the  root  filaments  of  the 
facial,  auditory,  glosso-j)haryngeal  and  vagus  nerves.  These 
passages  establish  free  communication  between  the  fourth 
ventricle  and  the  general  subarachnoid  space.  When  one  of 
these  processes  becomes  occluded,  the  recess  will  dilate  and 
form  what  Virchow*  terms  hydrocele  of  the  fourth  ventricle. 

*  "Die  Krankhaften  Geschwlilste,"  bd.  i.  183. 


NEURAL    CYSTS.  451 

This  pathologist  has  figured  a  specimen  that  had  attained 
the  size  of  a  cheny-stone  and  pressed  upon  the  floccuhis  and 
the  facial  nerve  :  remnants  of  the  choroid  plexus  of  the  fourth 
ventricle  projected  into  the  cyst.  Though  the  walls  of  this 
cyst  were  thin,  its  pressure  had  caused  paralysis  of  the  facial 
nerve. 

Recklinghausen*  has  described  a  case  in  which  there  was  a 
hydrocele  on  each  side  of  the  fourth  ventricle.  The  museum 
of  the  Middlesex  Hospital  contains  a  specimen  described  and 
figured  by  Sir  Charles  Bell,  who 
also  gives  a  history  of  the 
patient.  Attached  to  the  in- 
ferior surface  of  the  left  pedun- 
cle of  the  cerebellum,  close  to 
its  junction  with  the  pons,  is  a 
cyst  the  size  of  a  pigeon's  egg ; 
it  was  filled  with  fluid  the  colour 
of  urine.  The  fifth  nerve,  at- 
tenuated and  flattened,  appears 
to  issue  from  the  tumour,  and 

^„„   1,„    J-,, 3     ,1        ™    'j.  n  Fig.  230. — Hydrocele  of  the  fourth  ventricle. 

can  be  traced  along  its  walls  up    "        {After  sir  cimrus  Beii.) 

to  within    1    cm.    of  its    origin. 

The  seventh  and  eighth  nerves  are  lost  in  the  tumour  from 

within  5  mm.  of  their  origin  as  far  as  the  internal  auditory 

meatus.     (Fig.  230.) 

For  tumours  occurring  in  relation  with  the  cornucopia, 
which  might  be  confounded  with  "hydrocele  of  the  fourth 
ventricle,"  the  student  should  refer  to  the  chapter  on 
Psammomata. 

Cranial  Meningocele. — This  term  is  applied  to  a  hernial 
protrusion  of  the  meninges  of  the  brain  through  an  unossified 
portion  of  the  skull.  When  the  protrusion  consists  of  brain 
matter  as  well  as  membranes  it  is  described  as  a  meningo- 
encephalocele. 

Meningoceles,  using  the  term  in  its  general  sense,  occur 
in  definite  regions.  The  commonest  of  all  situations  is  the 
occiput ;  in  about  two-thirds  of  the  cases  the  tumour  projects 
in  this  part  of  the  skull.    Next  in  frequency  to  their  appearance 

*  Virchow's  "Archiv,"  bd.  xxx.,  s.  374. 


452 


PSEUnO-GYSTS. 


at  the  occiput,  meningoceles  appear  at  the  root  of  the  nose. 
In  other  regions  of  the  skull  they  are  excessively  rare.  It  is 
usually  stated  that  they  may  appear  at  the  anterior  fontanelle, 
but  critical  examination  of  the  descriptions  of  suspected  cases 
makes  it  probable  that  many  of  the  supposed  meningoceles 
were  dermoids,  and  this  was  demonstrated  in  the  cases 
described  by  Giraldes  and  Arnott  and  referred  to  at  page  301. 
Occipital  meningoceles  appear,  during  life,  to  protrude 
through  the  foramen  magnum ;  when  the  parts  are  dissected 
the  pedicle  will  be  found  to  make  its  way  through  a  gap  in 


Flocculus. 
231. — Occipital  meningo-encephalocele. 


(Museum.  Middlesex  Hospital.) 


the  supra-occipital  between  the  posterior  margin  of  the  fora- 
men magnum  and  the  occipital  protuberance.  This  space 
during  early  embryonic  life  is  occupied  by  a  fontanelle.* 

When  the  meningocele  is  examined  it  will  be  found  to  be 
covered  externally  by  skin,  and  usually  lined  internally  by 
tissue  directly  continuous  with  the  ependyma  of  the  ventricles. 
This  is  shown  in  Fig.  231.  In  this  specimen  the  cyst  was  as 
large  as  the  child's  head ;  the  cerebral  matter  projecting  into 
it  represented  the  corpora  quadrigemina,  whilst  choroid 
plexuses  floated  in  the  fluid  of  the  cyst.  The  cyst  itself 
probably  represented  a  dilated  fourth  ventricle.  There  was  no 
cerebellum,  but  the  flocculus  was  large  and  conspicuous. 

The  relation  of  the  flocculus  in  cases  of  occipital  meningo- 
cele is  of  importance.  On  reading  the  descriptions  of  reported 
cases  of  this  malformation  the  cerebellum,  if  referred  to,  is 
described  as  rudimentary  or  absent.     As  a  matter  of  fact,  in 

*  Med.-Chir.  Trans.,  vol.  Ixvii.,  p.  167. 


NEURAL    CYSTS.  453 

these  cases  the  cerebelkim  is  absent,  and  that  which  is  sup- 
posed to  represent  this  part  of  the  brain  is  an  enlarged  floc- 
cuhis.  Cleland*  has  pointed  out  that  the  floccukis  is  developed 
from  a  lateral  outgrowth  of  the  floor  of  the  third  encephalic 
vesicle,  whilst  the  cerebellum  is  developed  from  the  foremost 
part  of  the  roof  of  that  vesicle.  An  appreciation  of  this  fact 
throws  valuable  light  on  the  nature  of  occipital  meningocele, 
for  the  absence  of  the  cerebellum  indicates  that  the  hernial 
protrusion  is  the  third  encephalic  vesicle ;  instead  of  its  walls 
thickening  to  form  a  cerebellum,  tkey  become  passively  dilated 
into  a  cyst.  Indeed  tkis  form  of  meningocele  bears  much 
the  same  relation  to  the  fourth  ventricle  and  the  cerebellum, 
that  hydrocephalus  bears  to  the  lateral  ventricles  and  the 
cerebrum.  An  occipital  meningocele  might  not  inaptly  be 
described  as  liyclTocephaliis  limited  to  the  fourth  ventricle. 

My  observations  lead  me  to  believe  that  a  cranial  meningo- 
cele (a  cyst  formed  of  cerebral  membranes  only)  is  excessively 
rare. 

Occipital  meningo-encephaloceles  often  hang  so  low  as  to 
render  it  difficult  to  decide  whether  the  cyst  belongs  to  the 
cranium  or  to  the  cervical  region  of  the  spine.  There  is  reason 
to  believe  tkat  tke  pedicle  of  a  cranial  meningocele  may 
become  obliterated  so  as  to  cut  off  tke  communication  between 
tke  cyst  and  tke  subdural  space.  I  kave  never  kad  an 
opportunity  of  dissecting  a  specimen  in  wkick  tkis  kas 
kappened.  Suck  an  event  certainly  occurs  witk  spinal 
meningoceles. 

A  cranial  meningocele  is  sometimes  associated  witk  spina 
bifida ;  suck  a  combination  is,  as  a  rule,  accompanied  by 
gross  malformations,  especially  in  connection  witk  tke  lower 
limbs. 

It  kas  already  been  mentioned  tkat  dermoids  are  apt  to 
be  mistaken  for  meningoceles,  and  it  is  certain  tkat  meningo- 
celes are  sometimes  mistaken  for  dermoids.  Tkus  Powellf 
operated  on  a  Bengali,  twenty- two  years  of  age,  at  tke  Kona- 
para  Hospital,  Cachar,  for  a  supposed  sebaceous  cyst,  about 
the  size  of  a  tennis-ball,  situated  in  the  left  temporal  region. 
On  incising  the  cyst  it  was  discovered  to  be  a  meningocele 

*  Journal  of  Anat.  and  Phys.,  vol.  xvii.,  p.  257. 
t  Brit.  Med.  Journal,  1893,  vol.  i.,  p.  232. 


454  FSEUDO-CYSTH. 

and  the  hole  in  the  skull  would  admit  an  index  finger.  The 
cyst  was  removed  and  the  patient  recovered  rapidly. 

For  one  case  that  recovers  from  operations  on  a  cranial 
meningocele  ten  die. 

Individuals  with  meningoceles,  particularly  when  the  cyst 
is  large,  rarely  survive  their  birth  many  weeks.  Death  is 
usually  due  to  sloughing  of  the  sac  and  consequent  septic 
meningitis. 

Cephalhsematoma  is  the  name  given  to  a  collection  of 
blood  extravasated  in  consequence  of  injury  between  the 
vault  of  the  cranium  and  the  pericranium.  It  is  most 
commonly  seen  in  newly-born  children  that  have  pre- 
sented by  the  head.  The  swelling  in  these  cases  is  familiar 
to  practitioners  as  the  capwt  succedaneum.  In  the  course  of 
a  few  days  it  will  completely  disappear. 

Cephalhsematoma  arises  on  the  heads  of  children  as  a 
consequence  of  blows  or  falls,  and  in  the  majority  of  cases 
the  effused  blood  is  slowly  absorbed.  In  a  certain  proportion 
of  cases  suppuration  occurs,  and  the  hsematoma  is  converted 
into  an  abscess.  This  is  particularly  liable  to  occur  if  air  is 
admitted  either  through  abrasion  of  the  parts  at  the  time  of 
the  accident  or  by  exploratory  punctures  made  by  the  surgeon. 
In  most  cephalhsematomata  a  few  days  after  their  formation 
a  hard  ridge  forms  around  the  confines,  and  this  when  con- 
trasted with  the  pulpy,  yielding  sensation  imparted  to  the 
finger  by  the  rest  of  the  swelling  often  gives  rise  to  the  im- 
pression that  the  individual  has  sustained  a  depressed  fracture 
of  the  skull.  Knowledge  of  the  fact  is,  as  a  rule,  sufficient 
to  prevent  error  in  diagnosis. 

This  hard  ridge  is  interesting  in  another  way,  for  it  is 
liable  to  ossify.  In  many  cases  as  the  blood  is  absorbed  this 
ridge  likewise  disappears,  resembling  in  this  respect  callus 
around  a  fractured  long  bone.  In  rare  instances  adventitious 
bone  thus  formed  may  persist  and  form  a  large  bony  crater 
to' the  skull. 

A  very  remarkable  example  of  this  has  been  placed  on 
record  by  Treves.*  The  patient,  a  boy  eleven  years  of  age, 
had  a  large  swelling  on  the  head  strictly  limited  to  the  right 

*  Trans.  Clin,  Soc,  vol.  sxi.,  p.  285. 


NEURAL    CYSTS. 


455 


parietal  bone  and  covered  with  hairy  scalp.  (Fig.  232.)  The 
central  parts  of  this  swelling  were  soft,  fluctuating,  and  the 
seat  of  feeble  pulsation,  but  the  periphery  seemed  to  consist 
of  a  crater  of  hard  bone  firmly  adherent  to  the  scalp.  When 
this  boy  was  four  months  old  he  fell  from  his  father's  arm, 
his  head  striking  the  floor ;  a  bump  formed,  persisted,  and 
increased  in  size  as  the  boy  grew. 


Fig.  232.— Boy  with  an  old  ceplialhEematoma  over  the  right  parietal  bone.      {After  Silcock.) 


Upon  these  facts  Treves  came  to  the  conclusion  that  the 
tumour  was  primarily  a  cephalhsematoma,  a  considerable 
portion  of  the  wall  having  subsequently  ossified. 

Mr.  Silcock  brought  this  case  again  under  the  notice  of 
the  Clinical  Society,  and  it  was  referred  to  a  committee. 
This  committee  came  to  the  conclusion  that  the  tumour  was 
probably  a  cephalhydrocele.     {See  page  457.) 

The  formation  of  bone  in  the  peripheral  portions  of  a 
cephalheematoma  admits  of  simple  explanation.  Yirchow 
long  ago  pointed  out  that  the  pericranium  which  forms  the 
limiting  capsule  of  the  sweUing  is  a  bone-forming  membrane, 
and  though  separated  from  the  vault  of  the  skull  by  blood, 
still  pursues  its  bone-forming  function.     Another  remarkable 


456 


P8EUD0-GYSTS. 


character  of  a  cephalha3matoma  is  the  great  length  of  tiirie 
the  blood  will  remain  fluid  within  it. 

The  most  remarkable  cephalhsematoma  that  has  come 
under  my  notice  occurred  in  a  monkey  (Gehus  monachus). 
When  deposited  in  the  Zoological  Gardens  this  monkey  had 
on  its  head  a  large  rounded  tumour  (Fig.  233),  which  was  soft 


Fig.  233.— Monkey  (Cehus  monachus)  with  a  huge  cephalhseinatoma. 


and  fluctuating  at  the  top,  Avhere  a  feeble  pulsation  was  per- 
ceptible. That  portion  of  the  tumour  near  the  skull  was 
extremely  hard  and  felt  like  bone.  The  monkey  was  m 
excellent  health  and  seemed  in  no  way  encumbered  by  its 
burden.  It  continued  in  this  way  many  weeks ;  the  tumour 
did  not  increase  in  size,  but  the  hardening  of  its  walls  became 
more  extensive.  Some  months  later  the  monkey  fell  ill,  and 
as  it  seemed  in  great  sufi:ering  I  killed  it  by  means  of 
chloroform.  The  tumour  when  dissected  was  found  to  be  an 
old  cephalhematoma  with  extensive  ossification  of  its  walls 
(Fig.  234) ;  the  crater-like  arrangement  of  bone  on  the  top  of  the 


NEURAL    CYSTS. 


457 


skull  was  covered  in  by  pericranium  and  contained  dark  Huid 
blood.  The  frontal  bone  where  it  formed  the  floor  of  the 
cavity  was  so  thin  that  in  places  it  yielded  to  the  pressure  of 
the  finger,  like  parchment.  Some  of  the  ossicles  which  formed 
the  walls  of  the  cyst  were  bevelled  at  the  edges  and  serrated, 
so  as  to  articulate  one  with  the  other  like  Wormian  bones. 
Fragments  of  these  bones  were  examined  microscopically  and 
found  to  exhibit  the  structure  of  true  bone.     The  serrations 


Fig.  234. — Skull  of  Cebus  monaclnis,  sliuwiiig  the  bony  walls  of  tlie  cepliallisematoma 
and  a  group  of  Wormian  bones.    (^Mtiseuvi,  Royal  College  of  Surgeons.) 


at  the  edges  of  these  bones  were  probably  due  to  the  move- 
ments of  the  cyst  during  their  formation,  for  it  was  noted 
that  there  was  slight  pulsation. 

Cephalhydrocele. — This  is  usually  defined  as  a  pulsatile 
tumour  containing  cerebro-spinal  fluid  communicating  with 
the  interior  of  the  skull  through  an  abnormal  opening  the 
result  of  injury ;  it  does  not  demand  further  consideration 
here.* 


*  Smith,  St.  Earth.  Hospital  Reports,  vol.  xx.  233 ;  Lucas,  Guy's 
Hospital  Reports,  1876,  1878,  1881,  and  1884;  Godlee,  Trans.  Path.  Soc, 
xxxvi.  313. 


458  PSEIWO-CYHTS. 

Treatment. — It  is  rare  that  meningoceles,  even  small 
specimens,  are  submitted  to  treatment.  Sometimes  a  menin- 
gocele is  mistaken  for  a  wen  or  dermoid  and  excised  ;  during 
the  operation  the  surgeon  finds  that  he  has  opened  the  dura 
mater.  This  adventure  generally  ends  in  disaster ;  excep- 
tionally, it  has  cured  the  patient.  Even  in  successful  cases, 
hydrocephalus  has  followed  the  removal  of  the  meningocele.* 
(See  also  page  470).  In  several  cases  dermoids  have  been 
mistaken  for  meningoceles,  and  have  remained  undisturbed 
by  the  surgeon  until  some  change  in  them  has  led  to  the 
discovery  of  their  true  character. 

*  Wright,  Brit.  Med.  Journal,  1893,  vol.  i.  949. 


459 

CHAPTER    L. 

NEURAL  CYSTS  {concluded). 

Spina  Bifida. — The  term  spina  bifida  is  applied  to  congenital 
defect  in  the  union  of  the  laminae  of  one  or  more  vertebrae, 


Central  canal  of 

the  cord. 


fs;''^-;';  '  ■   V  i-'X  "- :""•'      :  ■%§ Expanded  nerve 


tissue. 


Fig.  235.— Lumbar  region  of  a  fuetus,  \Mtli  spina  bifida,  variety  myelocele.     (Mxiseum, 
Middlesex  Hospital.)    (After  Shattock.) 

associated    with    malformation    of    the    spinal    cord    or    its 
membranes. 

The  spinal  cord  and  a  large  part  of  the  brain  are  formed 
by  the  dorsal  coalescence  of  the  medullary  folds.  The  fusion 
of  these  folds  commences  in  the  thoracic  and  extends  into  the 
cephalic  and  caudal  regions.  For  a  short  time  after  coalescence 
the  embryonic  cord  and  superficial  epiblast  remain  in  con- 
tact. Gradually  they  become  separated  by  the  intrusion 
of  connective  tissue,  some  of  which  chondrifies  and  after- 
wards ossifies  to  form  vertebras  and  intervertebral  discs. 
In  the  early  stages  the  cord  has  a  longitudinal  extent  equal 
to  that  of  the  notochord,  and  this  equality  is  maintained 
for  some  time  after   the  closure  of  the   medullary   groove. 


460 


PSEUDO-GYSTH. 


Subsequently  the  vertebral  column  grows  at  a  greater  rate 
than  the  nerve-tube ;  the  result  is  that  at  birth,  the  medullary 
cone  at  the  end  of  the  cord  is  opposite  the  upper  border  of 
the  second  lumbar  vertebra. 

The  species  of  spina  bifida  are  determined  according  to 
the  stage  of  development  at  which  the  defect  occurs,  as 
determined  by  the  anatomy  of  the  parts.     They  are  : — - 

(1)  Myelocele,  (2)  syringo-myelocele,  (3)  meningo-mye- 
locele,  (4)  meningocele,  (5)  masked  spina  bifida  {spina  bifida 
occulta). 

1.  The  ')nedullary  folds  may  unite  imperfectly  and  give 
rise  to  a  myelocele. 

This  condition  is  well  illustrated  in  Fig.  235.     In  this  case 


Fig.  230. — Diagram  to  represent  tlie  microscopic  characters  of  a  transverse  section  of 
a  myelocele. 

the  cord  is  normally  formed  in  the  cervical  and  thoracic 
regions,  but  in  the  lumbar  portion  the  central  canal  suddenly 
opens  on  to  a  shallow  depression,  the  sides  of  which  are 
slightly  intumescent  and  then  become  gradually  continuous 
with  the  skin.  The  tissue  surrounding  the  furrow  represents 
the  medullary  folds  and  consists  mainly  of  very  vascular 
nerve-tissue.  When  fresh  this  area  is  of  a  bright  red  colour 
and  resembles  a  na3vus. 

When  this  pink  tissue  is  carefully  dissected  from  the 
underlying  vertebrse  and  prepared  for  the  microscope,  it 
will  exhibit  on  each  side  of  the  furrow  nerve-cells  embedded 
in  neuroglia,  intermixed  with  plexuses  of  arterioles,  venules, 
and  capillaries  (Fig.  236).  It  is  hard  to  determine  the  existence 
of  epithelium  on  the  surface  of  myeloceles,  because  there 
is  usually  some  inflammation  and  occasionally  sloughing. 


NEURAL    CYSTS.  461 

This  species  of  spina  bifida  is  fairly  common,  but  it  is  very 
rare  in  museums,  because  it  does  not  produce  a  tumour  in  the 
loin,  and  is  then  regarded  as  atypical  and  cast  away. 

Myeloceles  are,  according  to  my  observations,  more 
common  in  the  stillborn  than  in  children  that  survive 
their  birth  a  few  days.  I  am  of  opinion  that  is  the  commonest 
species  of  spina  bifida. 

Children  with  myeloceles  rarely  live  more  than  a  few 
days ;  the  central  canal  of  the  cord,  being  open,  allows  a 
continual  draining  away  of  the  cerebro-spinal  fluid,  Avhich 
soon  leads  to  death. 

2.  The  medullary  folds  unite  througJiout,  hut  fail  to 
separate  from   the    surface   epiblast. 

The  central  ca7ialbecom.es subsequently 
dilcded : — Syringo-myelocele. 

Syringo-myelocele  is  an  exces- 
sively rare  form  of  spina  bifida,  and 
cannot  be  determined  from  simpler 
forms  during  life.  When  the  parts 
are  dissected  the  distino^uishing  feature 
is  that  the  nerves  gain  the  interverte- 
bral foramina  by  runnine*  round  the    Fig.  ssT.-syringo-myeioceie  in 

'J  ~  transverse  section. 

convexity  of  the  cyst.     (Fig.  237.) 

Although  syringo-myelocele  is  very  rare  in  a  typical  form 
it  may  occur  in  combination  with  a  meningocele.  Glutton* 
has  carefully  described  an  example.     (Fig.  238.) 

3.  The  cord  is  normally  closed  but,  before  it  separates 
from  the  surface  epiblast,  becomes  compressed  by  a  collection 
of  fluid  within  the  meningecd  spaces  : — Meningo-myelocele. 

Probably  two-thirds  of  all  cases  of  spina  bifida  that 
survive  their  birth  are  meningo-myeloceles.  The  condition  is 
easily  recognised ;  there  is  a  deficiencj^  in  the  arches  of  the 
vertebrae,  usually  in  the  lumbar  region,  occupied  by  a  cyst 
of  variable  size.  Unless  inflamed,  or  flaccid  in  consequence 
of  leakage,  the  cyst  is  translucent  and  often  presents  a  pink 
tinge.  Its  most  posterior  part  is  somewhat  flattened,  and 
occasionally  a  shallow  median  groove  is  seen.  In  some 
specimens  quite  in  the  centre  of  the   cyst  there  is  a  small 

*  Trans.  Clin.  Soc,  vol.  xix.,  p.  99, 


462 


FSEUDO-GYSTS. 


umbilicus  marking  the  central  canal  of  the  cord.  At  the 
edge  of  the  cj'-st  where  its  walls  become  continuous  with  the 
skin  the  margin  is  slightly  raised,  and  immediately  beyond 
this  the  skin,  even  in  the  new-born,  may  present  a  circle 
of  long  hairs. 

Meningo-myeloceles'    are    often    associated    with    hydro- 
cephalus   and,   in  a  large  proportion   of  cases,  with   double 


Sac     of    the —    ""^i — 
meningocele.       \. 


Fig.  23S. — Syringo-myelocele  and  meningocele  in  longitudinal  section  ;  from  the  cervical  region. 

(After  Glutton.) 

talipes  equino-varus,  and  other  severe  deformities  of  the  lower 
limbs. 

On  transverse  section  of  a  meningo-myelocele  the  cord  is 
found  flattened  on  the  posterior  wall  of  the  cyst  like  a  strap, 
whilst  the  nerves  reach  their  respective  foramina  by  directly 
traversing  the  cavity  of  the  cyst.     (Fig.  239.) 

That  the  strap-like  band  of  nerve  tissue  on  the  posterior 
wall  of  the  sac  is  the  flattened  spinal  cord  was  demonstrated 
by  Shattock.*  He  cut  sections  of  this  part  of  the  cyst  and 
detected  the  central  canal.     (Fig.  240.) 

4.  The  cord  is  normal,  but  there  is  a  local  hernia  of  the 
membranes : — Meningocele. 

Protrusion  of  the  membranes  unaccompanied  by  the  cord 
is   by  no  means  common  in  spina  bifida.     Although  it   has 

*  Trans.  Clin.  Soc,  vol.  xviii..  Spina  Bifida  Report. 


NEURAL    CYSTS. 


463 


been  met  with  in  the  cervical  region  of  the  spine,  it  most 
frequently  affects  the  lumbo-sacral  region,  or  may  be  entirely 
confined  to  the  sacral  portion  of  the  spine.  Some  writers  on 
this  malformation  believe  that  the  hernial  protrusion  may 
make  its  way  between  the  arches  of  two  vertebrse  instead  of 
between  the  laminae  of  a  single  vertebra.  It  is  a  fact  that  the 
sac  of  a  meningocele  sometimes  emerges  through  a  very 
narrow  orifice,  and  in  a  few  instances  this  causes  the  cyst 
to  become  more  or  less  pedunculated,  and  may  lead  to 
occlusion  of  the  aperture  by  which  the  dural  space  and  the 
cyst  communicate  and  thus  isolate 
the  cyst. 

Virchow*  investigated  a  remark- 
able specimen  illustrating  this  process. 
The  patient  was  a  negro  child  born 
with  a  large  tumour  pendulous  from 
its  buttock.  (Fig.  241.)  The  tumour 
was  removed  in  Central  Africa  and 
sent  to  Virchow,  under  the  impression 
that  it  was  a  fatty  tumour.  Dissection 
revealed  a  central  space  in  the  tumour 
lined  with  dura  mater,  which  was 
covered  with  fat  intermixed  with 
muscle  tissue.  The  structure  and  arrangement  of  the  parts 
were  such  as  to  lead  Yirchow  to  the  opinion  that  the  tumour 
was  the  sac  of  a  meningocele.     (Fig.  242.) 

A  tumour  in  many  respects  similar  to  this,  save  that  it 
occurred  in  the  cervical  region  of  the  spine,  was  removed  by 
Solly  in  1856  from  a  woman  twenty-seven  years  of  age.  The 
description  of  the  case  is  accomj^anied  by  an  exceedingly 
interesting  clinical  history. f  Protrusions  of  dura  mater  un- 
accompanied by  cord  or  nerves  (meningoceles)  are  more  com- 
mon in  the  sacral  region  than  elsewhere.  In  some  instances 
the  membranes  emerge  through  the  deficiency  (hiatus  sacralis) 
normally  present  below  the  third  sacral  vertebra. 

This  will  perhaps  be  the  most  convenient  place,  in  which 
to  refer  to  an  abnormal  disposition  of  the  cord  which  I  have 
met  with  in  association  with  spina  bifida.     It  is  well  known 

*  "Archiv,"  bd.  c.  571. 

t  Med.  Chir.  Trans.,  vol.  xl.,  p.  19. 


;.  239. — Diagram  showing  men- 
ingo-myelocele  in  transverse 
section. 


464  PSEUDU-CYSTS. 

that  in  the  early  embryo  the  cord  extends  the  whole  length  of 
the  vertebral  column,  but  at  birth  the  apex  of  the  medullary 
cone  is  on  a  level  with  the  upper  border  of  the  second  lumbar 
vertebra.  I  have  placed  in  the  museum  of  the  Middlesex 
Hospital  a  spine  with  a  large  meningocele  in  the  sacral 
region ;  the  cord  runs  the  whole  length  of  the  neural  canal 
and  terminates  at  the  tip  of  the  sacrum.  The  specimen  was 
obtained  from  a  child  three  months  old. 

5.  The  cord  and  its  memhranes  are  normally  formed,  hv.t 
the  arches  of  one  or  more  vertebrce  are  defective,  but  there  is 
no  protrusion  of  the  meimbranes  or  cord  ; — Masked  spina 
BIEIDA  (spina  bifida  occulta). 

This  defect,  as  it  is  unaccompanied  by  a  cyst,  is  very  apt  to 


Fig.  240. — Microscopical  appearances  of  the  nerve  tissue  from  the  wall  of  a  meningo- 
myelocele showing  tlie  central  canal.     {After  Shattoclc.) 

be  overlooked.  An  interesting  feature  usually  associated  with 
this  condition  is  an  abnormal  growth  of  hair  in  the  loins. 
Hair  fields  of  this  description  may  be  localised  to  the  loin,  as 
in  the  original  case  described  by  Yirchow*  (Fig.  243),  and  the 
hair  may  form  a  long  tuft,  as  in  Fig.  244.  In  exceptional 
cases  an  abnormal  growth  of  hair  may  extend  from  the  loins 
over  the  buttocks  and  for  a  considerable  distance  down  the 
thighs. 

The  two  varieties  observed  in  the  distribution  of  hair 
in  these  cases  are  well  illustrated  by  the  arrangement 
adopted  by  artists  and  sculptors  in  their  representations  of 
fauns  and  the  goat-footed  satyrs  or  ajgipans.     (Fig.  245.) 

*  "Zeitschr.  flir  Ethnologie,"  1875,  bd.  vii.  280,  taf.  xvii.,  fig.  2. 


NEURAL    CYSTS. 


465 


Many  cases  of  spina  bifida  are  accompanied  b}^  an 
excessive  development  of  hair  in  the  loin  in  addition 
to  the  "  masked  "  species.  Attention  has  already  been  drawn 
to  the  fact  that  a  circlet  of  hairs  is  often  observed  on  the 


Fig.  241.— African  child  witla  a  pedunculated  tumour  (an  occluded  spina  bifida  sac) 
attached  to  its  buttock.     (After  VircJiow.) 


skin  immediately  bordering  the  sac  of  a  meningo-myelocele, 
even  in  new-born  babes. 

This  excessive  development  of  hair  associated  with  defec- 
tive closure  of  the  neural  arches  is  interesting  when  studied 
in  connection  with  the  luxuriant  growth  of  feathers  on  the 
heads  of  Polish  fowls,  for  in  many  of  these  birds  there  is 
defective  ossification  of  the  bones  of  the  cranial  vault.  An 
important  condition  often  associated  with  spina  bifida  occulta 
is  perforating  ulcer  of  the  foot.  Indeed  this  association  is 
now  so  well  recognised  that  in  every  case  of  perforating  ulcer 
of  the  foot,  occurring  in   young  patients,  it  is  the  duty  of 

E  E 


466 


FSEUDO-CYSTH. 


the  surgeon,  as  a  matter  of  routine,  to  examine  the  loins. 
The  girl  represented  in  Fig.  244  was  under  treatment  for  an 
ulcer  of  the  foot  and  caries  of  the  metatarsal  bones,  and  in  the 
course  of  the  clinical  investigation  the  spinal  defects  were 
detected. 

In  addition  to  non-union  of  the  arches  in  the  vicinity  of 
spina  bifida,  the  vertebrje  are  liable  to  be  defective  in  other 

ways,  and  of  these  the  most 
striking  is  the  absence  of  half  a 
vertebra — that  is,  half  the  cen- 
trum, with  its  pedicle  lamina, 
transverse,  articular  and  spinous 
processes,  are  wholly  wanting. 
The  persistent  half  of  such  a 
vertebra  has  the  characters 
shown  in  Fig.  246,  and  is  often 
ankylosed  to  the  vertebra  above 
and  below.  Sometimes  the  half 
vertebra  is  in  excess  of  the  or- 
dinary number.  Exceptionally, 
a  considerable  extent  of  the 
column  will  be  replaced  by  an 
alternating  series  of  half-verte- 
brae ;  this  is  especially  seen  when 
the  cervical  portion  of  the 
column  is  the  seat  of  spina  bifida. 
Half-vertebrse  occur  occasionally  independently  of  spina 
bifida ;  they  have  also  been  detected  in  the  spines  of  snakes 
and  calves.  I  have  found  them  in  fish  (sole)  and  in  the 
rabbit.  The  amount  of  disturbance  sometimes  caused  in  a 
vertebral  column  by  spina  bifida  is  very  remarkable.  Occa- 
sionally horizontal  processes  of  bone  project  from  the  vertebral 
centra  into  the  neural  canal,  and  sometimes  transfix  the 
cord.  Several  examples  have  been  carefully  described  in 
which  the  cord  has  bifurcated  and  coalesced  again  in  order 
to  enclose  a  beam  of  bone  crossing  the  canal  in  a  sagittal 
direction.* 


Fig.  242. —Tumour  tVoia  tlie  African  child 
{see  previous  ligure),  shown  in  section. 


*  Shattock,  Trans.  Clin.  Soc,  vol.  xviii. ;  EejDort  of  Spina  Bifida  Committee, 
p.  34  and  plate  vi. ;  and  Sir  George  HumpMy,  Journal  of  Anatomy  and 
Physiology,  vol.  xx.,  p.  585. 


NEURAL    GYSTS. 


467 


Complications  of  Spina  Bifida.  —  Unfortimately  all 
species  of  spina  bifida  are  apt  to  be  associated  with  other 
serious  conditions,  such  as  talipes  equino-varus,  single  and 
double,  and  other  gross  deformities  of  the  legs,  hydrocephalus, 
meningocele,  and  malformations  of  the  alimentary  canal,  such 
as  imperforate  anus  and  on  rare  occasions  imperforate  pharynx. 


Pig.  243,— Hair  field  on  the  loin  overlying  a  spina  bifida  occulta.     (After  Virchow.) 

Very  exceptionally  these  two  imperforate  conditions  of  the 
alimentary  canal  have  coexisted. 

The  most  serious  complication  of  spina  bifida  is  hydro- 
cephalus:  the  ventricular  cavities  of  the  brain  may  be 
abnormally  dilated  at  birth  ;  in  many  cases  the  hydrocephalus 
slowly  develops  during  the  first  few  weeks  of  infant  life,  and 
the  head  gradually  assumes  enormous  dimensions.  In  a 
small  proportion  of  cases  the  sac  of  the  spina  bifida  spon- 
taneously shrinks;  coincidently  with  this  the  fontanelles 
gradually  widen  and  hydrocephalus  develops.  I  have  in 
several  children  seen  hydrocephalus  supervene  when  the  sac 
in  the  loin  has  been  caused  to  shrink  by  artificial  means.    The 


468 


PSKUDO-GYSTB. 


specimen  from  which  the  drawing  (Fig.  227)  was   prepared 
occurred  secondarily  to  injection  of  the  sac. 

We  have  now  to  consider  the  various  modes  by  which 
spina  bifida  destroys  Ufe.  Of  all  the  species  of  this  malforma- 
tion, myelocele  is  the  most  fatal.  A  very  large  proportion  of 
foetuses  in  which  this  condition  is  present  are  stillborn :  the 

few  that  survive  their  birth 
rarely  live  longer  than  three 
days,  the  continued  leakage  of 
cerebro-spinal  fluid  being  suffi- 
cient to  explain  the  invariable 
brevity  of  their  lives. 

When  a  distinct  sac  is  present 
life  may  be  prolonged  many 
weeks,  even  when  the  sac-wall 
is  thin;  when  it  is  thick,  life 
may  be  prolonged  several  years  ; 
and  when  it  is  coinpletely  skin- 
covered  some  of  these  children 
survive  and  grow  up  to  be 
healthy  men  and  women.  The 
prospects  of  the  case  are  largely 
influenced  by  the  thickness  of 
the  sac-wall  and  the  absence  of 
complications,  especially  hydro- 
cephalus. 

In  many  cases,  especially 
when  the  walls  of  the  cyst  are 
thin,  the  tissue  is  apt  to  slough — an  event  that  allows  the 
sudden  escape  of  the  cerebro-spinal  fluid  and  may  ter- 
minate the  life  of  the  child  in  a  few  hours.  Children  often 
survive  this  accident  to  succumb  seven  or  ten  days  later  from 
septic  meningitis.  Exceptionall}'",  I  have  observed  children 
recover  from  rupture  of  the  sac  and,  escaping  meningitis, 
slowly  die  from  hydrocephalus.  Occasionally  the  sac  in  the 
loin  and  the  hydrocephalus  will  increase  simultaneously.  In 
such  a  case  pressure  on  the  anterior  fontanelle  will  increase 
the  tension  in  the  spina  bifida  sac,  and  vice  versa. 

The  duration  of  a  child's  life  with  sj)ina  bifida,  excepting 
the  "  masked  "  species,  is  very  uncertain ;  it  is  often  prolonged 


Fig.  244. — Hair  field  overlying  a  spina 
bifida  occulta ;  tliere  is  also  a  long  tuft 
on  the  cervical  region.    (Fischer. ) 


NEURAL    CYSTS. 


469 


when  the  nurse  and  mother  are  careful,  and  vigilantly  preserve 
the  sac  from  injury. 

That  spina  bifida  is  a  serious  affection  may  be  gathered 
from  the  figures  in  the  Registrar-General's  Reports;  about 
800  individuals  in  England  die  from  it  every  year.  This 
information  is  not  precise,  as   the  actual  number  of  cases 


Fig.  245.— >Egipan  sporting  with  a  faun  (p.  464).     {Bacchus  and  Silenus.) 


is  much  greater,  because  the  birth  of  the  stillborn  is  not 
registered.  No  facts  are  really  accessible  that  will  enable 
an  accurate  estimate  to  be  formed  of  the  real  frequency 
of  the  malformation. 

Treatment. — In  a  very  large  number  of  patients  treatment 
avails  nothing.  In  a  number  of  cases  attempts  have  been 
made  to  excise  the  sac  ;  but  now  the  pathological  anatomy  of 
the  condition  has  been  more  carefully  investigated  and  the 
difficulty  of  deciding  between  the  species  during  life  is  so 
well  recognised,  few  surgeons  will  be  rash  enough  to  excise  a 
spina  bifida  sac  save  in  exceptional  circumstances.  The 
operation  has  been  occasionally  successful ;  in  many  it  has 
produced  permanent  paraplegia. 


470 


PSEUDO-GYSTS. 


In  adults,  when  the  sac  has  become  pedunculated  and 
the  connection  with  the  subdural  space  occluded,  it  may 
be  removed  successfully,  as  is  well  illustrated  in  )Solly's 
classical  case  (page  463). 

All  rej^orted  cases  of  the  successful  removal  of  the  sac  of  a 
spina  bifida  from  adults  should  be  carefully  studied,  because 
in  some  instances  they  may  have  been  dermoids.  Meningo- 
celes sometimes  simulate  fatty  tumours  {see  page  15). 

The  treatment  which  gives  best  results  is  that  introduced 


Fig.  246.— Half-vertebra.     (After  SlmttocTc.) 


by  Morton  of  injecting  into  the  sac  a  small  quantity  (one  to 
two  drachms)  of  iodo-glycerine  solution.  This  consists  of 
iodine,  ten  grains ;  iodide  of  potassium,  thirty  grains ;  dis- 
solved in  an  ounce  of  glycerine.  This  method  emjoloyed  on 
suitable  cases  has  been  followed  by  a  large  measure  of  success. 
Suitable  cases  are  those  in  which  the  sac  is  small  and  has  a 
thick  Avail  (especially  if  the  sac  be  completely  covered  with 
skin)  and  there  is  an  absence  of  hydrocephalus.  The  best 
time  to  begin  this  treatment  in  favourable  cases  is  two  months 
after  birth.  It  must  be  borne  in  mind  that  h}- drocephalus  may 
supervene  after  the  sac  has  been  shrivelled  by  the  injections. 
However,   in    spite    of    numerous    failures    and    subsequent 


NEURAL    CYSTS.  All 

disappointment  in  apparently  successful  cases,  the  treatment 
by  iodo-glycerine  injections  is  not  only  the  safest,  but  the 
most  hopeful  method  that  has  yet  been  devised  for  the  relief 
or  cure  of  spina  bifida. 

The  Evolution  of  the  Central  Nervous  System.  —  The 
extraordinary  frequency  with  Avhich  the  membranous  and 
bon}'  coverings  of  the  central  nervous  system  are  malformed, 
induced  me  some  years  ago  to  investigate  the  abnormalities 
collectively  classed  under  the  term  spina  bifida,  with  the  hope 
of  obtaining  some  light  as  to  the  mode  of  evolution  of  the  brain 
and  spinal  cord,  for  as  I  pointed  out  in  1886,  the  pathological 
behaviour  of  the  central  canal  of  the  cord  indicated  that  it 
Avas  an  obsolete  passage.  In  1887  I  came  to  the  conclusion 
from  embryological  and  pathological  data  that  the  brain  and 
cord  were  in  all  probability  evolved  from  a  segment  of  the 
primitive  intestine."^  This  view  has  been  confirmed  since  by 
the  independent  researches  of  Gaskellf 

Tails. — This  account  of  spina  bifida  would  be  imperfect 
without  a  brief  notice  of  tails,  real  and  supposed,  in  the 
human  subject.  We  may  with  VirchowJ  arrange  tails  in  two 
classes,  true  and  false.  True  tails  may  be  complete  or  in- 
complete: the  most  perfect  or  complete  tails  contain  bony 
segments  (vertebrae),  as  in  the  case  of  cats  and  dogs :  the  less 
perfect  or  incomplete  tails  are  like  those  of  pigs,  soft  and 
flexible.  No  one  has  yet  reported  an  example  of  a  tail  in 
the  human  subject  containing  bony  elements.  Several  cases 
have  been  investigated  in  which  an  appendage  5  cm.  long, 
and  soft  like  a  pig's  tail,  has  been  found  directly  continuous 
with  the  coccygeal  vertebrae. 

Most  of  the  cases  reported  as  tails  were  examples  of 
congenital  sacro-coccygeal  tumours,  or  a  tuft  of  hair  covering 
a  masked  spina  bifida  (Fig.  244).  Tumours  supposed  to  be 
tails  were  in  some  cases  dermoids  (Fig.  149) ;  in  others  fatty 
tumours  (Fig.  14),  or  the  sacs  of  a  spina  bifida  (Fig.'  (241), 
and  in  many  teratomata  (Fig.  187). 

*  Brain,  vol.  x.  429. 

t  Journal  of  Physiology,  vol.  x.,  p.  153. 

+  "Berliner  Klin.,  Wochenschr.,"  1884,  No.  47. 


472 
CHAPTEK     LI. 

HYDATID   CYSTS. 

The  term  hydatid  formerly  covered  a  large  number  of  patho- 
logical productions,  but  the  term  is  now  restricted  in  human 
pathology  to  the  cystic  stage  of  Tcenia  echinococcus.  This 
cestode,  which  in  its  mature  form  inhabits  the  intestines  of 
dogs,  is  about  4  mm.  in  length  and  consists  of  four  segments, 
of  which  the  fourth  is  larger  than  the  rest  of  the  body  and  is 
the  only  segment  that  becomes  mature. 

The  eggs  of  this  worm  are  passively  conveyed  either  with 
food  or  water  into  the  alimentary  canal  of  man,  where  they 
are  hatched ;  the  embryo  migrates  from  the  intestine  into 
some  vascular  organ  or  tissue,  or  by  gaining  entrance  into  a 
blood-vessel,  is  passively  conveyed  into  some  distant  part  of 
the  body  and  becomes  transformed  into  a  cyst. 

The  cyst-wall  has  a  peculiar  structure ;  it  consists  of 
an  external,  highly  elastic,  lamellar  cuticle,  and  an  internal 
lining  consisting  of  granular  matter,  cells,  muscle  tissue,  and 
a  Avater-vascular  system. 

The  inner  lining  is  often  referred  to  as  the  parenchymatous 
layer.  In  addition  to  the  proper  tissues  of  the  cyst,  there 
is  a  more  or  less  complete  fibrous  capsule  derived  from  the 
adjacent  connective  tissue.  The  true  cyst  is  maintained  in 
apposition  with  the  fibrous  capsule  by  the  pressure  of  the 
contained  fluid  ;  when  this  is  removed  by  the  abstraction  or 
escape  of  the  fluid,  the  mother-cyst  at  once  collapses. 

When  the  hydatid  attains  the  size  of  a  walnut,  small 
vesicles  or  brood-capsules  develop  from  the  parenchymatous 
layer.  These  brood-capsules  develop  numbers  of  heads  or 
scolices.  The  scolex  when  fully  developed  is  about  0"3  mm. 
long,  is  furnished  with  four  sucking  discs  and  a  rostellum  of 
tiny  blunt  booklets ;  it  has  a  water-vascular  system  and 
numerous  calcareous  particles.  The  fore  part  of  the  scolex 
can  be  withdrawn  into  the  hinder  part ;  indeed  this  is  the 
position  in  which  they  are  usually  found. 

As  fresh  brood-capsules  and  scolices  are  formed,  the  cyst 
enlarges  and,  when  seated  in  an  organ  or  cavity  of  the  body 


HYDATIDS. 


473 


which  imposes  little  restraint  upon  its  growth,  it  may  attain 
enormous  proportions — e.g.,  hydatid  cysts  of  the  liver  have 
been  known  to  acquire  a  capacity  of  sixteen  pints. 

In  many  hydatids,  daughter-cysts  are  formed  from  brood- 
capsules  and  probably  from  scolices.  Cysts  containing  large 
numbers  of  these  translucent  thin-walled  vesicles  are  known 
as  echinococcus-colonies.     (Fig.  247.) 

Occasionally  hydatids  even  of  large  size  do  not  contain 
vesicles  or  brood-capsules  ;  such  are  said  to  be  sterile.  The 
walls  of  sterile  hydatids  exhibit  the  characteristic  lamination, 


Kidney 


Vesicles 


Mother-cyst.  Fibrous-capsule. 

Fig.  247.— Echinococcus-colony  in  the  kidney,     (ihiseum,  Middlesex  Hospital.) 


and  this  enables  the  nature  of  the  cyst  to  be  recognised  in 
otherwise  doubtful  cases. 

There  is  an  exceptional  mode  in  which  hydatids  manifest 
themselves  known  as  multilocular  hydatids  (Echinococcus 
midtilocularis,  Yirchow).  In  this  condition  the  vesicles  are 
of  small  size,  but  occur  in  great  number,  and  are  not  contained 
in  a  mother-cyst.  The  vesicles  in  such  cases  rarely  exceed 
a  pea  in  size,  but  the  majority  are  much  smaller  ;  very  many 
are  no  larger  than  inillet-  or  rape-seed.  This  variety  occurs 
most  frequently  in  the  shafts  of  long  bones.  (Fig.  248.)  They 
have  also  been  observed  in  the  spinal  canal. 


474 


FSEUD0-CYHT8. 


a  gelatinous  substance 
are    em- 


The  nuiltilocular  hydatid  also  occurs  in   the   liver  as  a 
firm  tumour,  Avhich  on  section  presents  trabeculse  of  dense 
fibrous  tissue,  Avhich  causes  it  to  assume  an  alveolar  appearance. 
The  alveoli  contain 
in   which   the   shrunken   vesicles 
bedded. 

Most  of  these  minute  vesicles  are  sterile, 
but  here  and  there  a  few  booklets  can  with 
iW  'f  patience  be  demonstrated.  Virchow*  was 
the  first  to  demonstrate  the  hydatid  nature 
of  such  tumours  in  the  liver ;  previously 
they  had  been  described  as  colloid  cancer. 
In  very  rare  instances  contracted  and 
shrunken  vesicles,  embedded  in  gelatinous 
material  and  surrounded  by  a  distinct 
cyst,  have  been  observed  in  the  liver.f 
No  satisfactory  explanation  has  yet  been 
advanced  to  account  for  this  curious  varia- 
tion in  the  development  of  hydatids. 
'a^lJ\  The   usual   mode   of    termination   of    a 

h3^datid  is  to  cease  to  grow ;  it  then  dies, 
shrivels  up,  and  calcifies,  assuming  a  friable 
appearance  like  old  mortar. 

When  the  cyst  continues  to  grow  its 
tendency  is  to  rupture  ;  the  great  tension 
exerted  by  the  accumulating  fluid,  and  espe- 
cially the  formation  of  daughter-cysts,  induces 
necrosis  of  portions  of  the  cyst-wall. 

When  hydatids  are  contiguous  to  hollow 

4Mi.      "^  viscera,    such    as    the    intestine,    stomach, 

trachea,  and    the    like,   the    cyst   is  apt   to 

come    into    contact    with    them,    and    the 

■^'"hydtti7s*of"thi'^s"mft  nmtual  pressure  leads  to  absorption  of  the 

Gra/fa™)'^™'*'  '■'^''^''^'  intervening  tissue,  and  allows  of  the  trans- 

inission  of  sfas,  air,  or  the  osmosis  of  fluids 

which  kill  the  parasite,  and  the  entrance  of  septic  organisms 

establishes  suppuration. 

*  Verh.  d.  Phys.  Med.  Ges.  ztc  Wnrzhurg,  1856,  bd.  vi.  84.    {See  also  Aust.  Med. 
Journal,  1884,  id.  171.) 

t  Sheild,  Med.-Chir.  Trans.,  vol.  Ixxv.  175. 


7 


HYDATIDS.  475 

In  many  instances  the  communications  between  hydatids 
and  hollow  viscera  are  so  free  that  the  contents  of  the  cyst 
are  evacuated.  In  some  instances  this  is  a  fortunate  termina- 
tion ;  but  frequently  it  is  a  catastrophe  to  be  dreaded,  as  it  may 
immediately  cause  death,  or  lead  to  secondary  changes  that 
have  ultimately  a  fatal  issue. 

In  rare  cases  the  contents  of  the  cyst  become  converted 
into  colloid  material  of  about  the  consistence  of  gelatine. 

Geographically,  the  hydatid  has  a  very  wide  distribution, 
which  corresponds  with  that  of  the  dog.  It  is,  however,  far 
more  frequent  in  some  regions  of  the  world  than  others. 
Iceland  is  notorious  for  the  frequency  with  which  its  in- 
habitants fall  victims  to  hydatids ;  after  allowing  great 
latitude  for  errors  in  the  direction  of  excess  in  calculating  its 
frequency,  hydatid-disease  must  be  regarded  in  the  light  of  a 
persistent  epidemic  so  far  as  that  island  is  concerned. 

Next  to  Iceland,  Silesia  is  usually  regarded  as  the  most 
infected  district  in  Europe.  In  Australia  hydatids  are  ex- 
cessively frequent,  and  whereas  most  of  the  monographs  on 
this  disease  in  its  clinical  aspects,  written  thirty  years  ago, 
were  founded  in  a  large  measure  on  observation  made  in 
Iceland,  during  the  past  ten  years  at  least  we  have  looked 
to  the  writings  of  Australian  physicians  and  surgeons  for 
information  on  the  pathology,  diagnosis,  and  treatment  of 
hydatids. 

In  Asia  the  disease  is  known  ;  it  occurs  in  India,  though  it 
is  far  from  common.  In  America  the  disease  is  not  frequent ; 
judging  from  the  few  references  to  it  in  American  literature, 
hydatids  appear  to  be  far  rarer  in  North  America  than  in 
the  British  Isles. 

Zoologically  hydatids  are  not  very  restricted,  for  they 
have  been  observed  in  monkeys,  lemurs,  cows,  sheep,  goats, 
deer,  camels,  antelopes,  giraffes,  horses,  asses,  zebras,  hogs, 
squirrels,  and  kangaroos  in  addition  to  man. 

Topographical  Distribution  in  Man. — Although  a  hydatid 
cyst  may  form  in  almost  any  organ  in  the  human  body, 
it  occurs  with  greater  frequency  in  some  organs  and  tissues 
than  in  others.  A  comparison  of  statistical  tables  compiled  in 
Iceland,  Germany,  Australia,  and  America  brings  out  most 
decisively  the  fact  that  hydatids  are  met  with  more  frequently 


476  PSEUDO-CYSTS. 

in  the  liver  than  in  all  other  parts  of  the  body  together ;  whilst 
in  other  organs,  such  as  the  breast,  thyroid  gland,  or  spinal 
cord,  the  literature  of  a  century  would  furnish  probably  under 
a  score  of  trustworthy  cases.  Hydatids,  in  addition  to  the 
above  organs,  haA^e  been  found  in  the  following: — kidneys, 
lung,  spleen,  bones,  suprarenal  capsule,  scrotum,  cerebrum, 
cerebellum,  heart,  axilla,  orbit,  etc.  It  is  a  curious  fact  that 
no  one  has  recorded  an  undoubted  example  of  a  hydatid  cyst 
in  the  ovary  or  testis. 

Hydatids  occur  singly  or  may  be  distributed  over  the  body 
in  great  numbers.  The  effects  to  which  they  give  rise  vary 
with  the  situation  and  dimensions  of  the  cyst.  For  instance, 
a  cyst  of  such  a  size  as  to  cause  no  inconvenience  when 
seated  in  the  liver  would,  if  growing  in  the  brain  or  walls  of 
the  heart,  soon  induce  death  from  mechanical  causes.  Again, 
a  hydatid  of  the  liver  will  often  attain  a  very  large  size  before 
causing  inconvenience  to  the  patient,  whereas  one  half  the 
size  situated  in  the  pelvis  would  produce  much  distress  by 
interfering  with  the  function  of  the  rectum  or  bladder.  On 
the  other  hand,  a  small  hydatid  of  the  liver  no  larger  than  an 
orange  when  accidentally  ruptured  and  its  contents  escaping 
into  the  peritoneal  cavity  may  rapidly  destroy  life,  but  a  cyst 
the  size  of  a  melon,  or  larger,  burstinof  into  the  rectum  will  not 
lead  to  much  trouble ;  but  even  a  small  cyst  so  seated  as  to 
rupture  into  the  trachea  will,  when  the  event  comes  to  pass, 
almost  inevitably  cause  death  by  suffocation.  Indeed  the 
ways  in  which  hydatids  kill  are  so  many  and  so  various  that 
they  will  be  dealt  with  under  each  organ. 

Liver. — Hydatids  are  more  common  in  the  liver  than  in 
any  other  organ.  The  frequency  with  which  these  cysts  occur 
in  the  liver  as  compared  with  other  viscera  is  not  due  to  any 
selective  power  on  the  part  of  the  echinococcus  embryo,  but 
may  be  attributed  to  the  fact  that  it  finds  its  way  into  the 
gastric  tributaries  of  the  portal  vein  and  is  passively  con- 
veyed into  the  gland.  As  a  rule  they  occur  singly  in  the 
liver,  but  many  instances  have  been  reported  in  which  three 
or  four  hydatids  have  been  present :  but  there  is  apparently 
no  limit  to  their  number,  for  the  museum  of  St.  Thomas's 
Hospital  contains  a  portion  of  a  liver  enormously  enlarged  in 
consequence  of  the  presence  of  a  multitude  of  hydatids. 


HYDATIDS. 


477 


The  relative  frequency  of  hydatids  in  the  hver,  the  large 
size  they  attain  in  this  organ,  and  the  risk  they  occasion  to 
life  have  caused  them  to  be  very  attentively  studied. 

When  the  cyst  ruptures  spontaneously  it  may  take  various 
directions.  Thus  it  may  burst  into  the  pleura  and  give 
rise  to  fatal  pleurisy.  Should  the  lung  be  adherent  to  the 
diaphragm,  the  cyst  may  open  into  it  and  the  contents  be 
discharged  through  the  bronchial  tubes  and  trachea.  Under 
these  conditions  gangrene  of  the  lung  may  follow  the  rupture. 

In  a  few  instances  the  cyst  has  burst  into  the  pericardium. 
Such   an  accident  is  rapidly  fatal,  as  the  inundation  of  the 


Fig.  249.— Multitude  of  minute  hydatids  on  the  pelvic  peritoneum,  probably  secondary  to  the 
tapping  of  a  cyst  in  the  liver.    [After  Graham.) 

pericardial  cavity  by  fluid  and  vesicles  embarrasses  the  heart. 
In  some  cases  death  has  followed  from  pericarditis. 

Rupture  of  a  large  cyst  into  the  peritoneal  cavity  leads  to 
serious  consequences,  but  when  the  cyst  is  small  it  may  lead 
to  general  infection  of  the  peritoneum  (Fig.  249).  In  a  case 
under  my  care  there  was  reason  to  believe  that  a  hepatic  cyst 
had  ruptured  into  the  lesser  bag  of  the  peritoneum,  for  the 
whole  of  the  small  omentum  was  thickly  beset  with  small 
hydatids.  Graham  records  a  similar  observation.  The  cyst 
has  been  known  to  rupture  into  the  stomach,  the  vesicles 
being  afterwards  vomited ;  and  in  a  few  cases  they  perforated 
into  the  intestine,  the  contents  of  the  cyst  being  discharged 
by  the  anus. 

Among  the  rarer  directions,  hydatids  have  been  known  to 
rupture  into  the  biliary  passages,  and  the  obstruction  caused 


478  PSEUDO-CYSTH. 

by  the  vesicles  has  induced  jaundice,  and  their  subsequent 
passage  along  the  common  duct  has  produced  biliary  colic. 

Another  excessively  rare  direction  is  for  the  cyst  to  rupture 
into  the  inferior  vena  cava,  the  contents  reaching  the  right 
side  of  the  heart. 

Cases  have  been  reported  in  which  the  pressure  of  a 
cyst  has  induced  atrophy  of  the  intercostals  and  its  contents 
discharged  externally.  They  have  also  been  known  to  burst 
externally  near  the  umbilicus.  Suppurating  cysts  may 
terminate  in  any  of  the  directions  mentioned  above. 

Hepatic  hydatids  may  cause  death  by  their  size  embar- 
rassing respiration,  or  by  pressure  on  important  organs,  such 
as  the  vena  cava,  producing  anasarca ;  or  hindering  the 
circulation  through  the  vena  porta  and  causing  ascites; 
whilst  suppuration  will  lead  to  exhaustion  or  induce  death 
by  septicaemia  or  pysemia. 

When  hydatid  fluid  escapes  into  the  peritoneal  cavity  it  is 
apt  to  produce  an  urticarial  eruption  known  as  the  hydatid 
rash.  It  usually  appears  shortly  after  the  cyst  has  been 
ruptured  or  punctured  ;  it  itches  intensely,  lasts  two  or  three 
days,  and  is  usually  accompanied  by  high  temperature  and 
sometimes  by  abdominal  pain.  It  is  referred  to  by  several 
observers.  Krabbe  writes : — "  A  curious  phenomena  is  habitu- 
ally observed  when  hydatids  rupture  into  the  peritoneal 
cavity  :  it  provokes  a  transient  urticaria."  * 

Finsenf  refers  to  two  cases  worth  mentioning  in  relation 
to  the  rash.  Paul  Helgason,  aged  twelve  years,  had  for  four 
years  a  large  tumour  in  the  right  hypochondrium  extending 
to  the  umbilicus.  The  lad  received  a  blow  from  a  cow's  horn 
upon  the  belly  that  caused  the  tumour  to  disappear.  Almost 
immediately  the  body  was  covered  with  a  rash  like  an  urticaria, 
but  it  soon  disappeared. 

In  another  patient,  a  pregnant  woman  had  a  hepatic 
hydatid  for  six  years.  Three  days  after  delivery,  whilst  lying 
quietly  in  bed,  she  was  suddenly  seized  with  acute  pain  in  the 
abdomen  ;  the  tumour  of  the  liver  disappeared,  and  in  a  short 
time  the  skin  presented  a  papular  rash. 

Hepatic  hj^datids  may  be  accidentally  ruptured  in  a  variety 

*  "  Recherclies  Helminthologiques  en  Danemark  et  en  Islande."  1866. 
t  Arch.  Gen.  de  Med.,  1869,  xiii.  23. 


HYDATIDS.  479 

of  ways — such  as  blows,  falls  on  the  belly,  by  the  wheels 
of  a  cart,  or  during  an  embrace  in  "  a  moment  of  exuberant 
affection."  ^ 

The  Heart. — Hydatids  of  the  heart  occur  under  two  con- 
ditions : — (1)  The  cyst  may  form  in  the  muscle  tissue  of  the 
heart — that  is,  in  the  walls  of  the  ventricles  or  auricles ;  or 
(2)  the  vesicles  are  conveyed  to  the  cavities  of  the  right  side 
of  the  heart  as  emboli,  in  consequence  of  the  rupture  of 
a  hydatid  cyst  into  some  large  vessel  such  as  the  vena 
cava. 

When  a  cyst  forms  in  the  heart  it  may  develop  in  the 
walls  of  the  auricles.  Of  this  many  cases  have  been  recorded.f 
In  the  walls  of  the  ventricle  they  appear  to  be  rare  and  never 
attain  a  large  size.j  Graham  states  that  in  the  Sydney 
University  pathological  museum  there  is  a  specimen  in  which 
a  hydatid  occupies  the  interventricular  septum. 

Cardiac  hydatids  usually  terminate  the  life  of  the  patient 
suddenly,  sometimes  without  rupture  ;  but  as  a  rule,  the  fatal 
event  is  due  to  this  cause,  the  cyst-contents  being  discharged 
into  the  pericardial,  auricular,  or  ventricular  cavities.  When 
the  cysts  open  into  the  right  cavities  of  the  heart  the  vesicles 
may  be  carried  as  emboli  into  the  pulmonary  artery.  If  into 
the  left  cavities,  they  may  be  carried  into  the  systemic  arteries. 
Oesterlen§  recorded  a  case  in  which  a  girl,  twenty-three  years 
of  age,  developed  gangrene  of  one  leg.  This  was  amputated 
and  she  died  of  pyaemia.  A  cyst  the  size  of  a  pigeon's  egg 
situated  in  the  cardiac  wall  had  burst  into  the  left  auricle  ; 
hydatid  membrane  was  discovered  in  adherent  thrombi  in 
the  common  iliac  artery,  and  an  entire  vesicle  was  found  in 
the  deep  femoral  artery. 

The  Lungs. — Hydatids  occur  in  the  lungs  under  two 
conditions: — (1)  The  cyst,  for  it  is  usually  single,  may 
be  situated  wholly  within  the  substance  of  the  lung,  and  in 
most  cases  chooses  the  lower  lobe,  especially  of  the  right 
lung  ;  or  (2)  it  may  grow  in  the  tissue  immediately  beneath 

*  Treves,  Trans.  Clin.  Soc. ,  vol.  xxi.  82. 

f  Moxon,  Trans.  Path.  Soc,  vol.  xxi.,  p.  99 ;  and  Graham,  ''  Hydatid 
Disease,"  p.  134. 

X  Trans.  Path.  Soc,  vol.  xv.  247. 

§  Virchow's  "  Archiv,"  bd.  xlii. ,  p.  404. 


480  PSEUDO-GYHTS. 

the  pulmonary  pleura  and  project  as  an  outgrowth  from  the 
lung  into  the  pleural  cavity. 

When  the  cysts  are  small  they  occasion  little  incon- 
venience, but  increasing  in  size  they  compress  the  lung  and 
lead  to  hsemoptysis. 

Apart  from  the  mere  pressure  effects  produced  by  the 
cyst,  it  is  liable  to  rupture  into  the  bronchial  tubes,  and  pieces 
of  membrane  and  vesicles  are  coughed  up  and  indicate  the 
nature  of  the  case.  When  the  cyst  communicates  with  a 
bronchial  tube,  suppuration  of  the  cyst  is  the  inevitable 
consequence.  Should  the  cyst  rupture  into  the  pleural 
cavity,  empyema  is  the  usual  result.* 

It  is  well  to  bear  in  mind  that  because  hydatid  vesicles 
and  membrane  are  coughed  up  it  does  not  necessarily  follow 
that  the  cyst  is  seated  in  the  lung.  Hepatic  hydatids  are 
sometimes  evacuated  by  this  route. 

Hydatids  of  the  Kidney. — A  large  number  of  cases  ot 
renal  hydatids  have  been  recorded.  The  cyst  may  occupy 
the  substance  of  the  kidney  or  grow  immediately  beneath 
the  capsule.  In  each  situation  the  hydatid  may  attain  a  very 
large  size  and  lead  to  extensive  atrophy  of  the  renal  tissue. 
When  of  small  size  they  rarely  give  rise  to  trouble  or  even 
inconvenience  during  life,  and  their  existence  is  only  known 
in  the  course  of  a  post-mortem  examination  (Fig.  247). 

Large  hydatids  appear  as  fluctuating  tumours  in  the  loin 
and  simulate  hydronephrosis. 

There  are  good  reasons  for  believing  that  the  greater  pro- 
portion of  hydatids  of  the  kidney  rupture  into  the  pelvis  of 
the  organ,  the  fluid  and  vesicles  passing  down  the  ureter  to 
be  discharged  by  the  urethra.  This  is,  of  course,  the  most 
satisfactory  mode  of  termination,  except  perhaps,  death  of  the 
parasite  with  subsequent  calcification.  Now  that  surgeons 
are  so  interested  in  renal  tumours  it  is  very  probable  that 
more  accurate  information  will  soon  be  accessible. 

Bones. — Hydatids  occur  much  more  frequently  in  long 
than  in  flat  bones,  but  in  either  situation  they  are  extremely 
rare.  When  occupying  the  medullary  cavity  of  a  bone  they 
induce  atrophy  of  the  shaft  from  the  persistent  pressure  they 

*  Curnow,  Trans.  Path.  Soc,  vol.  xxxiv.,  p.  24. 


HYDATIDS.  481 

exercise,  and  at  length  the  bone  breaks  (spontaneous  fracture) 
from  some  trivial  injury.  In  some  of  the  cases  operations 
have  been  undertaken  for  the  relief  of  abscesses  supposed  to 
be  due  to  necrosis,  and  when  the  bone  has  been  opened  up, 
hydatid  vesicles  have  escaped.  Hydatids  appear  in  the 
medullary  cavity  of  bones  in  two  forms : — 

(1)  The  cyst  may  be  sterile.  An  example  of  this  is  pre- 
served in  the  museum  of  the  Royal  College  of  Surgeons  ;  the 
cyst  occupies  the  medullary  cavity  of  the  humerus  of  an  ox. 

(2)  There  is  no  mother-cyst,  hut  the  inedullary  cavity  is 
occupied  by  a  multitude  of  vesicles.  This  appears  to  be  the 
usual  condition  in  which  hydatids  occur  in  bone. 

Hydatids  have  a  preference  for  the  tibia  among  bones  : 
the  museum  of  Guy's  Hospital  contains  one,  and  the  museum 
of  St.  Mary's  Hospital*  two  examples. 

In  Coulson's  f  case  the  tibia  was  occupied  by  hundreds 
of  vesicles.  The  patient  was  a  woman  twenty-five  years 
of  age.  The  cyst  extended  to  near  the  ankle.  The  symptoms 
had  existed  for  nearly  eight  years. 

GrahamJ  has  recorded  and  figured  a  good  example 
in  the  humerus.  (Fig.  248.)  The  patient  was  a  woman, 
thirty-five  years  of  age,  who  had  a  tense  swelling  in  the  lower 
part  of  the  arm :  this  was  incised,  when  pus  and  a  number 
of  small  vesicles  escaped.  The  arm  was  amputated  at  the 
shoulder  joint.  At  the  lower  part  of  the  bone  the  shaft 
was  converted  into  a  fusiform  sac  in  which  there  were  large 
numbers  of  vesicles,  most  of  them  entire  and  healthy.  The 
head  and  lower  extremity  were  the  only  parts  of  the  bone 
free  from  the  parasite.     There  was  no  trace  of  a  parent- cyst. 

Webb  §  has  recorded  a  case  that  occurred  in  the  shaft  of 
the  femur.  The  patient,  a  man  twenty-six  years  of  age,  com- 
plained of  pain  over  the  trochanter  of  the  left  femur  ;  soon  a 
swelling  appeared.  Eventually  this  was  incised,  and  two 
or  three  hundred  vesicles  in  various  stages  of  development 
and  degeneration  escaped.  There  was  no  appearance  of  a 
niother-cyst. 

*  Cat.  Museum,  St.  Mary's  Hospital,  1891. 
t  Med-Chir.  Trans.,  vol.  xli.,  p.  307. 
X  "  Hydatid  Disease,"  p.  132.   "•  ■ 

§  Ausf.  3Icd.  Journal,  1891.        - 
F  F 


482  PSEUD0-GY8TS. 

When  the  hydatids  occupy  the  ends  of  bones  they  may 
break  into  the  adjacent  joint.  In  the  well-known  case  of 
Travers  the  cysts  occupied  the  lower  end  of  the  femur  and 
the  upper  end  of  the  tibia.  The  cysts  that  had  suppurated 
communicated  with  each  other  through  the  knee  joint.* 

Carline's  f  extraordinary  specimen,  represented  in  Plate 
IX.,  is  almost  the  counterpart  of  this. 

Thomas  has  reported  a  case  which  grew  in  the  ilium. 
The  museum  of  St.  Bartholomew's  Hospital  contains  half  a 
pelvis  in  which  hydatids  occupied  the  ilium  and  the  sacrum. 
Yirchow  refers  to  a  specimen  of  hydatids  in  the  sternum. 
They  have  also  been  found  in  an  ungual  phalanx. 

Hydatids  of  the  thyroid  gland  are  very  rare ;  they  usually 
terminate  by  bursting  into  the  trachea.  This  is  always  a 
fatal  accident.  Hydatids  have  been  observed  in  the 
adrenal. 

Birch-HirschfeldJ  reported  an  instance  of  a  hydatid  lying 
in  the  cavity  of  the  vermiform  appendix,  which  was  dilated 
to  twice  the  thickness  of  the  thumb.  It  contained  the  remains 
of  hydatid  membrane,  which  presented  under  the  microscope 
the  characteristic  lamination.  The  appendix  contained  a 
great  number  of  semi-transparent  vesicles,  varying  from  a 
pin's  head  to  a  pea  in  size  :  most  of  these  were  sterile.  The 
communication  between  the  appendix  and  the  csecum  was 
obliterated.  The  walls  of  the  appendix  and  its  mucous  mem- 
brane were  atrophied  from  the  pressure  exerted  by  the  cyst, 
and  presented  mosaic-like  impressions  caused  by  the  pressure 
of  the  vesicles.  The  patient  was  a  man  thirty-eight  years 
of  age. 

The  Mamma. — Echinococcus  cysts  in  this  gland  are  very 
rare :  records  of  at  least  twenty  cases  are  accessible.  The 
patients  were  in  nearly  all  instances  adult  women.  The 
disease  takes  the  form  of  a  slowl}''  increasing,  painless  swelling, 
which  may  involve  the  whole  breast  or  project  as  a  smooth, 
elastic,  fluctuating  tumour  from  some  portion  of  its  circum- 
ference. These  cysts  may  exist  in  the  breast  for  ten  years 
or  longer  without  producing  much  inconvenience  :  they  have 

*  Cat.  St.  ThoiBas's  Hospital  Museum,  1890,  part  i. 
t  Brit.  Med.  Journal,  1892,  vol.  ii.,  p.  632. 
X  Arch.  d.  Heilhund(,  1871,  p.  191. 


PLATE  IX.  Lower  two-thirds  of  a  Femur,  with  the  upper  fourths  of  the 
Tibia  and  Fibula.  The  remnants  of  the  Femur  and  Tibia  are  fenestrated 
osseous  shells,  in  consequence  of  the  pressure  exercised  by  muitilocular 
hydatids  which  began  in  the  Femur,  invaded  the  knee-joint  and  involved 
the  Tibia.  There  is  a  sequestrum  in  the  Femur  measuring  7'5  cm.  by 
4  cm.     Carline's  case.     (Museaiu,  Royal  College  of  Surgeons.)    i  nat.  size. 


HYDATIDS.  483 

been  reported  with  a  capacity  of  twenty  ounces.  Occasionally 
the  cyst  suppurates. 

Diagnosis,  in  countries  where  the  echinococcus  is  not 
comm,on,  is  very  difficult  without  the  assistance  of  an  ex- 
ploratory puncture.  This  will  clear  up  the  case.  In  most 
of  the  cases  that  occurred  in  England  the  nature  of  the 
swelling  was  revealed  when  the  surgeon  made  an  incision  into 
the  breast  for  the  purpose  of  removing  it. 

DraAvings  of  mammary  hydatids  are  given  by  Astley 
Cooper,*  Bryant,f  and  others. 

The  Subperitoneal  Tissue  and  Omentum. — Hydatids 
occur  in  these  situations  frequently  in  great  numbers,  and  are 
often  of  large  size.     They  may  be  pedunculated  or  sessile. 

Muskett:]:  reported  a  remarkable  case  in  which  the  patient 
was  supposed  to  be  suffering  from  a  hydrocele  the  size  of  an 
emu's  egg.  When  tapped  it  was  found  to  be  a  hydatid  cyst. 
As  a  rule,  when  abdominal  hydatids  are  numerous  they  are  of 
small  size ;  when  solitary  they  may  be  very  large.  Should  a 
solitary  cyst  be  sterile,  its  true  nature  is  liable  to  be  over- 
looked. 

Hydatids  grow  in  the  mesentery,  the  meso-rectum,  or 
between  the  layers  of  the  broad  ligament  of  the  uterus.  In 
men  many  cases  have  been  recorded  in  which  a  cyst  of  large 
size  grew  in  the  connective  tissue  between  the  bladder  and 
rectum. 

Many  echinococcus  cysts  described  as  growing  in  relation 
with  the  liver,  spleen,  and  uterus  really  lie  in  the  tissue 
immediately  beneath  the  serous  covering  of  these  organs,  and 
are  in  a  sense  subperitoneal.  If  these  cases  be  included  it  will 
be  clear  that  the  subperitoneal  tissue  is  an  exceedingly 
favourite  situation  for  hydatids. 

Connective  Tissue  of  the  Trunk  and  Limbs. — Many  cases 
have  been  recorded  in  which  hydatids  have  been  found  in  the 
axilla,  orbit,  posterior  triangle  of  the  neck,  etc.  Their  nature 
is  rarely  suspected  until  the  swelling  is  incised. 

Brain. — Hydatids  of  the  brain  occur  either  in  connection 
with   the   meninges   or   in   the   brain  substance.     In   either 

*  "  Diseases  of  the  Breast,"  plate  ix. 

f  "  Diseases  of  the  Breast,"  1887,  plate  viii. ,  figs.  3  and  4. 

:j:  Atist.  Med.  Gaz.,  1886,  p.  57. 


484  PSEUDO-CYSTS. 

situation  they  are  not  common.  The  cerebrum  seems  to  be 
the  most  frequent  seat  of  the  cyst,  and  the  right  hemisphere 
lodges  them  twice  as  often  as  the  left.  In  the  cerebellum 
they  are  rare.  When  the  cyst  occupies  the  membranes  it 
presses  upon  and  produces  a  bay  in  the  cortex  of  the  cerebrum. 
In  any  part  of  the  brain  they  rarely  attain  a  large  size,  as  their 
position  causes  them  to  bring  about  serious  disturbances.  It 
is  often  remarked  by  those  who  have  recorded  examples 
of  intracranial  hydatids  that  the  damage  produced  by 
the  cyst  on  the  brain  is  out  of  proportion  with  the 
symptoms ;  but  the  same  is  equally  true  of  almost  all  cerebral 
tumours. 

Intracranial  hydatids  are  not  furnished  with  the  thick 
adventitious  ca23sule  that  surrounds  them  in  most  other 
situations  ;  hence  the  cyst-wall  is  extremely  delicate,  and  it  is 
remarkable  that  hydatid  cysts  of  the  brain  are  nearly  always 
sterile. 

Echinococcus  colonies  are  found  occasionally  in  the  brain. 
Mudd'''  has  described  a  case  that  occurred  in  a  girl  of  twelve 
years.  The  colony  was  lodged  in  the  right  motor  area  of  the 
cerebral  cortex,  and  produced  absorption  of  the  overlymg 
bones  and  bulged  externally.     It  was  successfully  treated. 

Spinal  Canal. — Hydatids  occur  in  connection  with  the 
spinal  canal  under  three  conditions : — 

(1)  The  hydatids  are  situated  entirely  luithin  the  canal. 
Such  cases  are  divisible  into  two  sets :  (a)  those  inside  the 
dura  mater — such  cases  have  been  described  by  Bartelsf  and 
Woodij: ;  or  (h)  the  cysts  lie  in  the  connective  tissue  between 
the  bone  and  dura  mater,  as  in  a  case  recorded  by  Maguire.§ 
In  several  of  these  cases  the  hydatids  were  of  the  multilocular 
variety.  Thus  in  Maguire's  case  there  was  a  large  number  of 
vesicles,  varying  in  size  from  a  pin's  head  to  that  of  a  small 
chestnut,  lying  between  the  dura  mater,  the  last  cervical  and 
upper  six  thoracic  vertebree.  Ransom  1|  has  published  a  com- 
plete account  of  a  case   in  which    a   hydatid   the    size  of  a 

*  Intemat.  Jour.  Med.  Sci.,  1892,  p.  412. 

t  Iteuf.  Arch.  f.  Klin.  Med.,  bd.  v.,  s.  108. 

i  Aust.  Med.  Journal,  1879,  p.  222. 

j  Brain,  vol.  x.,  p.  451. 

II  Brit.  Med.  Journal,  1891,  vol.  ii.  1144. 


HYDATIDS.  485 

cliestnut  grew  from  the  arch  of  the  tenth  thoracic  vertebra 
and  produced  paraplegia. 

(2)  The  hydatids  affect  the  vertebrce  and  extend  into  the 
canal. 

Ogle"^  has  described  an  example  of  this  in  which  the  C3'st, 
containing  a  large  number  of  vesicles,  was  lodged  in  the 
spinous  process  of  the  seventh  cervical  vertebra  ;  it  projected 
into  the  canal  and  pressed  upon  the  cord. 

(3)  The  hydatids  groiv  in  the  tissues  outside  the  vertehroi, 
which  are  secondarily  involved,  the  cyst  extending  into  the 
canal. 

Several  examples  of  this  are  known.  Wilks  and  Moxonf 
describe  a  preparation  in  which  numerous  small  hydatids 
extended  widely  in  the  subpleural  tissue  in  the  neighbourhood 
of  the  spine,  which  they  perforated  by  eroding  the  vertebrae 
and  then  entered  the  neural  canal  and  compressed  the  cord 
producing  paraplegia.  In  this  case  the  cysts  were  not  enclosed 
by  a  mother-cyst  (multilocular  hydatids). 

Cruveilhier :]:  has  given  a  good  example  of  this  which 
occurred  in  a  woman  thirty-eight  years  of  age.  It  grew 
among  the  muscles  in  the  vertebral  groove  and  made  its  way 
between  the  arches  of  the  twelfth  thoracic  and  first  lumbar 
vertebrae,  and  compressed  the  cord  without  entering  the  dural 
sheath. 

Treatment. — The  principles  on  which  hydatid  cysts  are 
treated  by  surgeons  consist : — 

1.  In  removiiig  the  cyst  entire  whenever  this  is  possible. 
Failing  this  : — 

2.  To  incise  the  cyst-ivall,  evacuate  the  contents,  and  ivhen- 

ever  possible  remove  the  true  cyst,  and  cdlow  the  cavity 
bounded  by  the  capsule  to  close  by  granidation. 
The  particular  manner  of  carrying  out  the  treatment 
varies  with  the  situation  of  the  cyst.  The  simplest  condition 
is  when  a  hydatid,  or  even  six  or  eight,  the  size  of  cocoa-nuts 
hang  from  the  great  omentum.  In  such  a  case  the  tumours 
are  exposed  through  an  abdominal  incision  and  withdrawn ; 
the  omental  pedicles  are  tied  and  the  cysts  cut  away.     In 

•■■•  Trans.  Path.  Soc,  vol.  xi.,  p.  299. 

t  Fath.  AnatoiiDj,  1875,  p.  64. 

j  Anat.  Fath.,  liv.  xxxv.,  plate  vi.,  i:g's.  1  and  2. 


486  PSEUDO-CYSTS. 

many  cases  they  are  so  firmly  adherent  to  surrounding 
structures  that  they  cannot  be  removed  ;  it  is  then  necessary 
to  incise  the  fibrous  capsule,  or  tear  through  them  carefully 
with  forceps  and  expose  the  mother-cyst,  which  is  then  easily 
enucleated.  The  empty  capsules  give  no  trouble.  Suppurating 
hydatids  demand  incision  and  drainage. 

In  the  case  of  hydatids  in  the  liver,  incision  and  drainage 
give  excellent  results.  Great  care  should  be  taken  to 
evacuate  the  cyst-contents  thoroughly,  and  whenever  possible, 
without  the  exercise  of  too  much  violence,  the  mother-cyst 
should  be  enucleated.  The  subsequent  decomposition  of  this 
highly  albuminous  tissue  is  a  source  of  very  great  danger  to 
the  patient. 

All  such  methods  of  meddling  with  abdominal  hydatids, 
as  aspiration,  punctures  with  trocars,  and  electrolysis,  should 
be  unhesitatingly  condemned.  No  one  should  venture  to 
tap  or  aspirate  an  abdominal  cyst  for  diagnostic  purposes. 
Such  interference  often  works  incalculable  harm  ;  whereas  an 
exploratory  incision  carried  out  by  a  surgeon  familiar  with 
abdominal  surgery  is  an  operation  infinitely  safer  than  a 
thrust  in  the  dark  from  a  trocar.  I  have  never  seen  an 
exploratory  puncture  of  the  belly  do  good ;  often  it  misleads, 
frequently  converts  a  simple  into  an  anxious  case,  and 
occasionally  encompasses  the  death  of  the  patient. 

Hydatids  in  the  cerebral  cortex  have  been  localised, 
exposed  by  trephining,  and  successfully  drained.  Verco*  is 
of  opinion  that  in  about  one-third  of  the  cases  of  hydatids  of 
the  brain  the  cysts  communicate  with  the  lateral  ventricles  ; 
hence  when  a  cyst  is  opened  by  operation  the  cerebro-spinal 
fluid  also  escapes,  drains  the  ventricles,  and  causes  death.  To 
obviate  this  he  suggests  that  no  drainage-tube  should  be 
employed,  the  flaps  being  closely  stitched  so  as  to  seal  up  the 
cavity. 

In  the  case  of  bones  the  treatment  consists  of  incision, 
evacuation  of  the  vesicles,  and  drainage.  Exceptionally,  when 
the  bone  is  seriously  damaged,  fractured,  or  a  large  joint 
invaded,  amputation  has  been  necessary. 

Large  hydatid  cysts  of  the  lung  require  to  be  treated  on 
the  principles  of  empyema. 

*  Brit.  Med.  Journal,  1892,  vol.  ii.  1066. 


487 


CHAPTER    LII. 

THE    ZOOLOGICAL   DISTRIBUTION    OF   TUMOURS. 

Throughout  the  course  of  this  book  many  incidental 
references  have  been  made  to  tumours  occurring  in  verte- 
brate animals ;  it  will  perhaps  be  useful  to  summarise  our 
knowledge  on  this  matter,  because  there  are  many  facts  con- 
nected with  it  of  great  interest  in  their  bearing  on  the  Biology 
of  Tumours. 

As  man  in  his  bodily  structure  is  kindred  with  the  brutes, 
it  would  be  expected  that  the  various  tumours  known  to 
occur  in  him  would  have  their  counterparts  in  vertebrata 
generally.  For  example,  we  should  expect  to  find  lipomata, 
especially  as  fat  is  a  tissue  so  widely  distributed  in  the  animal 
kingdom ;  but  this  is  not  the  case,  and  the  few  that  have 
come  under  my  observation  occurred  chiefly  in  horses,  oxen, 
and  sheep,  and  belong  mainly  to  the  subserous  species.  {See 
page  8.)  In  stall-fed  oxen  excessive  accumulation  of  fat 
is  common  in  the  subperitoneal  tissue,  especially  in  the 
omentum ;  but  such  formations  accompany  general  obesity, 
and  do  not  come  into  the  category  of  tumours.  It  is  a 
fact  that  in  man  the  largest  lipomata  usually  occur  in 
particularly  lean  individuals. 

Osteomata  are  very  generalised  tumours ;  they  have  been 
met  with  in  several  species  of  fish.  Gervais*  has  described 
many  examples ;  reference  has  already  been  made  to  the 
singular  condition  of  the  bones  in  Ghcetodon  (page  29).  The 
bony  outgrowths  to  which  the  term  exostosis  is  applicable  are 
of  fairly  common  occurrence  in  mammals,  and  their  frequency 
on  the  bones  of  horses  can  only  be  appreciated  after  a  visit  to 
a  veterinary  museum. 

In  ree^ard  to  odontomes,  it  would,  of  course,  be  antici- 
pated  that  such  tumours  occur  more  frequently  in  other 
mammals  than  in  man,  in  consequence  of  the  peculiar  con- 
ditions of  growth  that  prevail  in  such  orders  as  Rodentia 
and  Frohoscidea. 

*  Journal  de  Zoologie,  vol.  iv.,  1875. 


488  TUMOURS. 

The  marmot,  agouti,  and  porcupine  have  suppHed  me 
with  very  interesting  specimens,  and  I  have  obtained  as  many 
as  four  large  odontomes  from  the  mouth  of  one  marmot. 
Many  excessively  large  odontomata  have  been  obtained  from 
horses  and  elephants.  Goats,  sheep,  bears,  and  kangaroos 
have  furnished  me  with  excellent  specimens  of  fibrous 
odontomes.     Some  of  them  are  described  in  chapter  iv. 

Myomata  furnish  material  for  speculation.  Probably 
the  uterine  myoma  is  the  commonest  tumour  that  affects 
the  human  female,  but  it  is  a  singular  fact  that  uterine 
myomata  are  almost  unknown  in  mammals.  The  only 
specimen  that  has  come  under  my  observation  occurred  in 
a  female  baboon,  and  was  rather  a  general  enlargement  of  the 
uterus  than  an  actual  tumour. 

Even  among  domestic  mammals,  such  as  the  mare,  cow, 
ewe,  goat,  bitch,  and  cat,  uterine  myomata  are  almost  un- 
known ;  indeed,  the  details  of  the  few  recorded  cases  are 
stated  in  such  vague  terms  that  the  descriptions  are 
useless. 

When  the  situations  of  uterine  myomata  in  women  come 
to  be  examined  it  will  be  seen  that  they  are  extremely 
common  in  the  walls  of  the  uterus,  and  they  also  grow  from 
the  cervix,  but  they  are  excessively  rare,  indeed  almost 
unknown,  in  the  Fallopian  tube.  In  the  majority  of  mammals 
the  greater  part  of  the  uterus  consists  of  two  muscular  tubes, 
the  uterine  cornua ;  whereas  in  women  the  tubes  become  con- 
fluent to  form  a  median  uterus.  Seeing  that  myomata  are 
common  in  the  wall  of  this  compound  uterus,  but  almost 
unknown  in  the  Fallopian  tubes  and  in  bicornuate  uteri,  it 
would  seem  to  favour  the  view  that  uterine  myomata  may  in 
some  cases  arise  from  "  rests  "  in  the  uterine  walls  due  to 
imperfect  coalescence  of  the  Mlillerian  ducts,  in  the  same  way 
that  dermoids  of  the  sequestration  species  are  so  common  in 
the  lines  of  coalescence  in  the  embryo. 

Of  all  the  connective-tissue  tumours,  sarcomata  have  the 
widest  zoological  distribution,  and  they  occur  with  very  great 
frequency,  especially  the  round-celled  and  the  spindle- celled 
species.  They  are  met  Avith  in  fish,  birds,  rats,  mice,  horses, 
sheep,  dogs,  cats,  goats,  oxen,  monkeys,  bears,  marsupials — 
indeed,  in  all  the  orders  of  mammals  and  in  snakes.  Sarcomata 


ZOOLOGICAL  DISTRIBUTION  OF  TUMOURS.  489 

in  dogs  often  grow  with  extreme  rapidity,  and  this  may  in 
some  measure  be  explained  by  their  elevated  temperature 
(101-8='  Fahr.). 

Periosteum  and  skin  appear  to  be  the  common  situations 
attacked  by  sarcomata,  especially  in  dogs.  In  horses  and 
dogs  I  have  been  able  to  satisfy  myself  that  spindle-celled 
sarcomata  often  contain  hyaline  cartilage.  Retinal  sarcomata 
have  been  observed  in  horses  and  sheep,  and  I  have 
obtained  an  exceUent  specimen  from  the  eye  of  a  monkey. 
Melano-sarcomata  in  the  horse  have  been  already  referred 
to  on  page  116. 

Supposed  sarcomata  in  the  lower  mammals,  especially 
the  lympho-sarcomata  of  dogs,  need  careful  study  from 
those  engaged  in  bacteriology,  for  the  rapid  manner  in 
which  they  grow  and  the  profound  effects  they  produce 
on  the  general  health  of  these  animals,  suggests  very  strongly 
that  they  are  the  product  of  some  very  active  species  of 
micro-parasite. 

The  occurrence  of  epithelial  tumours  in  animals,  wild  or 
domesticated,  is  a  subject  of  great  interest  in  its  bearing  on 
cancer  and  its  allies.  Unfortunately  few  trust  worth}^  observations 
are  forthcoming.  For  instance,  a  cursory  review  of  veterinary 
periodical  literature  would  give  colour  to  the  opinion  that 
epithelioma  of  the  penis  is  a  common  disease  in  bulls  and 
in  horses,  but  on  looking  into  the  matter  a  re-examination 
of  suspected  cases  shows  clearly  enough  that  many  supposed 
examples  of  epithelioma  are,  as  a  matter  of  fact,  instances  of 
penile  warts,  and  all  competent  histologists  who  have  inquired 
into  the  matter  are  unanimous  that  penile  epithelioma  in 
horses  and  bulls  is  excessively  rare. 

Warts  are  common  enough  in  dogs  and  lambs,  not  only 
about  the  mouth  and  hps,  but  along  the  coronets  of  lambs 
and  on  the  pads  of  the  feet  of  dogs  and  many  carnivora. 
Warts  being  abundant,  it  naturally  follows  that  wart-horns 
would  be  frequent.  This  inference  is  confirmed  by  reference 
to  examples  described  in  chapter  xx. 

An  extended  inquiry  concerning  adenomata  and  carcino- 
mata  in  mammals  generally,  reveals  an  extraordinary  condi- 
tion of  things.  Wild  mammals  in  a  state  of  nature  and  those 
living  in  confinement  appear  to  be  absolutely  free  from  cancer. 


490  TUMOURS. 

On  one  occasion  I  found  a  mammary  adenoma  in  a  phalanger  ; 
it  is  preserved  in  the  museum  of  the  Royal  College  of  Surgeons, 
and  this  single  specimen  represents  the  extent  of  my  know- 
ledge concerning  adenomata  and  cancers  in  Avild  mammals. 
It  is  fair  to  emphasise  this  statement  by  mentioning  that 
during  the  eight  years  I  was  in  close  attendance  ,  in  the 
Prosector's  room  of  the  Zoological  Society's  Gardens,  I  was 
particularly  on  the  look-out  for  tumours  of  all  kinds. 

Adenomata  occur  in  domestic  mammals.  The  bitch  is 
especially  liable  to  tumours  of  the  mammary  gland  that  are 
analogous  to  the  large  cystic  adenoceles  of  women.  These 
tumours  are  sometimes  so  large  as  to  exceed  in  weight  the 
carcase  of  the  bitch  to  which  they  are  attached.  As  far  as 
my  observations  extend,  these  tumours  do  not  infect  the 
lymph  glands  nor  become  disseminated.  Large  cystic  adeno- 
mata, with  intracystic  processes,  are  occasionally  seen  in  the 
udders  of  cows. 

The  mammary  glands  of  cats  are  liable  to  a  disease  that 
is  histologically  identical  with  mammary  cancer  in  women, 
but  cancer  such  as  attacks  the  human  mamma  is  unknown 
in  cows,  mares,  ewes,  goats,  or  bitches. 

Dogs  are  liable  to  a  species  of  tumour  that  occurs  with 
tolerable  frequency  in  the  skin  around  the  anus.  It  exhibits 
the  structure  of  a  sebaceous  adenoma  and  after  attaining 
the  size  of  a  walnut  ulcerates.  Such  tumours  quickl}^  recur 
after  removal,  but  they  do  not,  as  a  rule,  infect  the  lymph 
glands  or  become  disseminated. 

Very  little  is  known  concerning  the  occurrence  of  dermoids 
in  mammals.  Considering  the  frequency  of  these  tumours  in 
man  it  might  be  imagined  that  they  would  be  widely  distributed 
among  mammals.  Of  sequestration  dermoids,  a  fair  number 
of  specimens  have  been  obtained  from  sheep  and  oxen,  but 
most  of  these  belong  to  the  implantation  variety.     (Page  305.) 

Ovarian  dermoids  have  been  observed  in  the  mare  and  the 
ewe.  Dermoid  patches  on  the  conjunctiva  have  been  reported 
many  times  in  all  species  of  domestic  mammals  except  the  ass 
and  cat. 

Teratomata  are  common  enough  among  domestic  animals, 
and  many  examples  have  been  described  in  fish,  frogs,  and 
other  batrachians,  lizards,  snakes,  birds,  rabbits,  hares,  etc. 


ZOOLOGICAL  DISTRIBUTION  OF  TUMOURS.  491 

The  frequency  of  cystic  tumours  in  vertebrata  generally 
forms  a  striking  contrast  to  the  infrequency  of  connective- 
tissue  and  epithelial  tumours.  Such  conditions  as  hydro- 
nephrosis, congenital  cystic  kidney,  dilatations  of  the  vitello- 
intestinal  duct  have  been  observed.  Hydrocele  of  the  tunica 
vaginalis  is  rare  because  the  funicular  pouch  m  mammals 
retains  its  connection  with  the  general  peritoneal  cavity 
throughout  life.  Cysts  arising  in  connection  with  the  central 
nervous  system  have  been  observed  in  foals,  pigs,  and  calves. 
Hydrocephalus  is  fairly  frequent,  but  spina  bifida  is  rare. 
(Esophageal  diverticula  are  often  seen  in  horses,  and  these 
useful  mammals  are  exceedingly  liable  to  synovial  cysts  and 
ganglia. 

Parasitic  cysts  are  very  common  in  animals  of  all  kinds. 


492 
CHAPTER    LIII. 

THE    CAUSE    OF   TUMOURS. 

It  is  a  very  difficult  task  to  discuss  the  cause  of  tumours; 
nevertheless  it  is  far  easier  to-day  than  it  was  fifty  years  ago. 
Pathological  histolos'v  has  tauo-ht  us  to  narrow  the  term 
"  tumour  "  within  certain  limits,  and  bacteriology  has  enabled 
us  to  reject  many  morbid  conditions  that  were  formerly 
called  tumours. 

Yirchow  rendered  excellent  service  in  separating  the 
Infective  Granulomata,  and  it  was  afterwards  demonstrated 
that  many  of  them — e.g.,  tubercle,  glanders,  actinomycosis, 
etc. — are  caused  by  micro-organisms.  Another  example 
of  greater  precision  in  the  use  of  terms  is  furnished  by 
hydatids ;  this  name  was  formerly  used  in  the  loosest 
sense,  but  is  now  restricted  to  the  cystic  stage  of  Taenia 
ecliinocoeciis.  Increased  precision  in  the  use  of  names  may 
be  expected  to  continue  with  the  advance  and  diffusion  of 
knowledge  concerning  tumours,  and  by  degrees  the  name 
"  tumour "  Avill  have  a  still  narrower  meaning.  Recent  in- 
vestigations in  the  pathology  of  morbid  growths  teach  us  to 
look  for  a  variety  of  causes.  Take,  for  example,  the  interesting 
speculation  usually  termed  Cohnheim's  theory,  in  which 
tumours  are  supposed  to  spring  from  unutilised  fragments  of 
tissue,  or  residues,  some  of  which  may  be  due  to  faults  or  em- 
bryonic irregularities.  Such  residues  or  "  tumour-germs  "  may, 
early  in  life,  even  in  the  fcetus,  develop  into  tumours,  or  remain 
many  months,  or  even  years,  quiescent,  then  suddenly,  and 
apparently  without  provocation,  take  on  active  growth.  This 
theory,  unsupported  as  it  was,  without  the  least  evidence  of  a 
concrete  character,  was  advanced  by  Cohnheim  as  an  explana- 
tion of  the  origin  of  connective-tissue  and  epithelial  tumours. 
The  great  argument  against  it  w^as  to  the  effect  that  unutilised 
embryonic  tissue  (tumour-germs)  had  not  been  demonstrated. 
The  theory,  however,  indicated  a  line  of  inquiry  in  which 
observation  and  experiment  have  demonstrated,  in  regard 
to  some  genera  of  connective-tissue  tumours  and  very  many 
dermoids,  that  it  offers  a  solution  of  several  difficult  problems. 


THE   CAUSE   OF  TUMOURS.  493 

It  is  undeniable  that  our  knowledge  of  unutilised  tissue  and 
vestiges  of  organs  has  of  late  years  been  widened,  and  it  will 
be  useful  to  summarise  briefly  what  is  now  known  in  regard 
to  them. 

It  is  desirable  to  arrange  tumour-germs  in  two  groups — 
viz.,  vestiges  and  rests.  The  term  vestige  should  be  reserved 
for  structures  that  are  remnants  of  organs  functional  in 
vertebrates  lower  than  man ;  for  those  organs  that  are  of 
importance  to  the  embryo,  but  useless  in  the  adult ;  and  a  few 
which,  thouQfh  utilised  in  the  male,  are  useless,  or  almost 
useless,  in  the  female,  and  vice  versa ;  as  well  as  for  those 
structures  which,  as  far  as  we  know,  serve  no  useful  purpose 
in  any  vertebrate  at  present  living,  but  were  doubtless  of 
importance  in  their  ancestors.  Many  examples  of  vestiges 
and  their  relation  to  tumours  have  already  been  considered  in 
the  preceding  pages — e.g.,  the  mesonephros,  the  parovarium 
Gartner's  duct,  the  urachus,  the  vitello-intestinal  duct,  the 
central  canal  of  the  cord,  etc. 

The  term  rests  should  be  reserved  for  detached  fragments 
of  glands  and  isolated  portions  of  tissue  and  epithelium.  That 
they  are  the  sources  of  many  tumours  there  can  be  no  doubt, 
and  it  is  equally  certain  that  when  more  attention  is  devoted 
to  the  question,  many  additional  examples  of  "  rests "  will 
come  to  light.  The  number  already  known  is  by  no  means 
insignificant. 

The  easiest  demonstrable  example  occurs  in  connection 
with  the  spleen.  It  is  the  normal  condition  to  find  in  the 
gastro-splenic  omentum  of  a  child  at  birth  a  miniature  spleen 
or  splenculus.  It  is  no  uncommon  event  to  find  two  or  three 
splenculi,  and  as  many  as  five  have  been  counted.  In  many 
instances  these  accessory  spleens  atrophy,  but  frequently  they 
may  be  detected  in  adults.  When  the  abdominal  viscera  are 
transposed  the  spleen  is,  as  a  rule,  represented  by  a  cluster  of 
splenculi. 

The  pancreas  furnishes  a  similar  example.  Several  in- 
stances have  been  recorded  in  which  an  accessory  pancreas 
has  been  detected.  It  is  usually  situated  in  the  wall  of  the 
duodenum  or  jejunum,  between  the  serous  and  muscular  coats, 
and  it  is  important  to  remember  that  these  detached  fragments 
may  occur  at  some  distance  from  the  main  gland.    Accessory 


494  TUMOURS. 

thyroid  glands — neglecting  those  which  he  in  the  tract  of  the 
thyro-glossal  duct — illustrate  this,  for  they  have  been  detected 
on  a  level  with  the  episternal  notch,  and  in  the  trachea  as  low 
as  its  bifurcation. 

Eests  associated  with  an  adrenal  occur  in  the  kidney, 
immediately  beneath  the  capsule,  as  cuneiform,  yellowish- 
white  nodules  ;  they  have  been  described  as  renal  lipomata, 
and  there  is  reason  to  believe  that  they  are  occasionally  the 
germs  of  very  large  tumours.     {See  page  98.) 

Detached  fragments  of  liver  occasionally  occur  in  the 
falciform  ligament  and  in  the  neighbourhood  of  the  transverse 
fissure ;  but  no  one,  so  far  as  I  know,  has  succeeded  in  demon- 
strating the  origin  of  a  tumour  from  these  rests;  but  it  is 
easily  couceivable  that  they  might  under  exceptionable  con- 
ditions play  the  part  of  tumour-germs. 

As  fragmentary  livers,  so  to  speak,  occur  beyond  the  actual 
hepatic  territory,  it  is  very  probable  that  portions  of  glandular 
tissue  may  be  isolated  within  the  liver  itself,  and  there  are 
strong  grounds  for  the  belief  that  certain  adenomata  of  the 
liver  do  arise  from  such  sequestrated  tracts  of  hepatic 
tissue.  This  mode  of  origin  of  adenomata  gains  strongest 
support  from  our  knowledge  of  mammary  tumours.  Outlying 
pieces  of  mammary  gland  are  occasionally  met  with,  merely 
joined  to  the  main  gland  by  connective  tissue,  and  it  is 
reasonable  to  believe  that  they  are  the  source  of  some  of  the 
encapsuled  adenomata  that  occur  at  the  periphery  of  the 
breast.  The  mammary  rests  must  not  be  confounded  with 
accessory  mammae  arising  as  neomorphs  in  the  adjacent  skin, 
especially  in  the  skin  of  the  axilla.  It  is  also  probable  that 
isolated  encapsuled  portions  of  gland  are  the  source  of  the 
fibro-adenomata  so  common  in  the  mamm?e  of  young  women. 
{See  page  221.)  The  same  explanation  holds  good  for  some 
of  the  small  cystic  tumours  of  the  parotid  gland. 

Tracts  of  epithelium  occur  as  vestiges  and  as  rests.  As 
vestiges,  epithelial  tracts  occur  in  the  tongue — the  lingual 
duct ;  in  the  neck — branchial  clefts ;  in  the  naso-palatine 
suture — Stenson's  canal ;  in  the  brain — infundibulum  ;  and 
in  other  situations  the  vestigial  character  of  some  of  the 
tracts  and  their  tendency  to  form  tumours  has  been 
already    described.      The    tumour  -  forming    proclivities    of 


TBI]  CAUSE  OF  TUMOURS.  495 

others  lias  been  abundantly  demonstrated  in  the  section  on 
Dermoids. 

As  rests,  epithelial  tracts  occur  in  the  line  of  the  meso- 
palatine  suture,  in  the  gums  derived  from  enamel-organs,  and 
in  the  lines  of  coalescence  of  the  trunk,  the  scalp  and  face. 
In  these  situations  they  give  rise  to  tumours.  Epithelial  rests 
may  be  produced  accidentally  by  surface  epithelium  carried 
into  the  deeper  tissues  by  cuts,  punctures,  etc.  These  give 
rise  to  small  tumours,  when  the  conditions  are  favourable, 
known  as  implantation  cysts.     (See  page  304  and  Fig.  250.) 

Rests  are  known  in  connection  with  non-epithelial  tissues, 
but  they  do  not  admit  of  such  ready  demonstration.  In  the 
neighbourhood  of  epiphysial  lines,  particularly  in  the  long 
bones  of  rickety  mdividuals,  islets  of  cartilage  have  long  been 
known,  and  it  is  not  unreasonable  to  believe  that  such  belated 
fragments  may  be  the  source  of  some  enchondromata  and 
osteomata. 

It  is  certainly  probable  that  some  forms  of  uterine  myo- 
mata  arise  from  sequestrated  portions  of  the  uterine  tissue, 
especially  encapsuled  myomata  of  the  uterine  walls.  (See 
page  488.) 

It  is  curious  that  many  vestiges  and  rests  lie  latent  several 
years.  Take,  for  example,  accessory  thyroids :  rarely  they 
give  trouble  before  puberty  ;  many  never  cause  the  least  incon- 
venience, and  a  few  become  active  even  late  in  life.  Goitre  of 
the  parenchymatous  kind  is  occasionally  congenital ;  but  I  am 
not  aware  that  the  cystic  variety  is  common  until  the  accession 
of  puberty ;  after  this  event  it  is  frequent.  Mammary  adeno- 
mata are  of  common  occurrence  between  the  sixteenth  and 
thirtieth  years,  but  they  are  almost  unknown  before  the  four- 
teenth year.  The  best  instance  of  this  sudden  awakening  may 
be  studied  in  the  parovarium ;  its  ducts  are  quiescent  during 
the  early  years  of  life.  So  far  as  I  have  collected  the  evidence — 
and  my  search  has  been  a  broad  one — there  is  no  case  on 
record  of  a  parovarian  cyst  occurring  in  a  girl  under  fifteen 
years.  Between  the  ages  of  sixteen  and  twenty-live  years 
a  large  number  of  parovarian  cysts  have  been  removed. 

Take  cysts  of  the  paroophoron :  they  are  almost  unknown 
before  the  twenty-fifth  year  of  life.  Certain  it  is  that  small 
paroophoritic  cysts  have  been  detected  in  infant  ovaries,  but 


496  TUMOURS. 

these  were  not  appreciable  to  clinical  observation.  The  exist- 
ence of  tiniiour-germs  is  demonstrable  in  the  case  of  cysts. 
There  is  scarcely  a  cyst  known  to  which  pathologists  cannot 
ascribe  an  origin  in  some  pre-existing  cluct,  tube,  gland,  or 
vestige.  One  of  the  most  extraordinary  features  connected 
with  some  cysts  is  the  physiology  of  secretion.  For  instance, 
a  parovarian,  or  a  simple  ovarian  cyst  containing  only  two  or 
three  ounces  of  fluid  in  a  tense  sac  with  thin  walls,  may  in  spite 
of  the  intracystic  pressure  continue  to  increase  until  it  attains 
a  capacity  of  three,  four,  or  more  gallons.  Hydrocephalus  and 
meningoceles  illustrate  the  same  inexplicable  phenomenon,  for 
they  are  devoid  of  glands  and  lack  epithelium,  at  least  in  their 
late  stages. 

In  the  case  of  simple  tumours  we  know  that  they  arise 
from  a  matrix  similar  in  structure  to  the  tumour.  These 
facts  should  cause  us  to  keep  a  keener  look-out  for  isolated 
fragments  (rests)  of  organs  and  tissues.  A  very  suggestive  in- 
stance is  a  fatty  tumour  of  the  broad  ligament  of  the  uterus. 
Under  normal  conditions  there  is  no  fat  between  the  layers  of 
this  serous  ligament,  yet  lipomata  have  been  observed  in  that 
situation,  sometimes  of  great  size.  A  careful  examination  of 
the  parts  has  taught  me  that  the  parovarium  is  sometimes 
buried  in  a  layer  of  rich  yellow  fat. 

The  tumours  to  which  Cohnheim's  theory  cannot  be  re- 
garded as  in  any  sense  applicable  are  the  sarcomata,  epithelio- 
mata,  and  cancers. 

Although  Cohnheim's  theory  of  tumours  concerns  a  limited 
number  of  genera,  it  commands  attention  because  it  is  in  itself 
a  brilliant  generalisation,  and  has  served  a  valuable  purpose  in 
directing  inquiry  upon  particular  lines,  which  has  led  to  a 
great  extension  of  knowledge  in  regard  to  vestiges  and  rests. 

Before  discussing  the  probable  cause  of  cancer  it  is  neces- 
sary to  consider  some  points  in  its  morphology.  A  com- 
prehensive study  of  the  histology  of  cancer  indicates  that  the 
method  of  dividing  it  into  three  varieties — scirrhus,  ence- 
phaloid  (medullary),  and  colloid — is  not  only  misleading,  but 
the  division  has  no  structural  basis.  It  is  also  of  great  im- 
portance to  bear  in  mind  that  many  misconceptions  arise 
from  the  circumstance,  that  pathologists  have  been  in  the 
habit   of  interpreting   the   structure  of  cancers  from  plane 


THE    CAUSE    OF    TUMOURS.  497 

sections,  without  in  tlie  least  taking  into  consideration  tlie 
relation  of  a  given  section  to  tlie  entire  tumour  ;  hence  a 
scirrhous  cancer  was  said  to  be  composed  of  an  alveolar  mesh- 
work  of  fibrous  tissue,  the  alveoli  enclosing  epithelial  cells. 
If,  instead  of  drawinsf  conclusions  from  one  or  two  sections 
selected  haphazard,  a  number  of  consecutive  sections  be  taken 
and  a  composite  picture  framed  from  them,  it  will  at  once 
become  clear  that  the  cellular  alveoli  are  sections  of  glandular 
acini  and  ducts  filled  with  cells  cut  in  various  directions, 
some  transverse,  others  oblique,  and  many  in  their  long  axes. 
This  fact  is  admirably  illustrated  in  the  case  of  rectal  cancer  ; 
frequently  sections  of  these  tumours  take  the  form  of  closely 
packed  cylinders.  In  others  a  number  of  epithelium-lined 
bays  or  recesses  are  found,  and  in  some  parts  of  the  tumour 
these  spaces  are  of  irregular  shape  and  embedded  in  young 
connective  tissue.  When  the  sections  are  examined  col- 
lectively we  find  that  these  alveoli  with  their  epithelial  con- 
tents are  really  greatly  enlarged  Lieberklihnian  follicles  cut 
in  various  planes.  What  is  true  of  the  rectum  holds  equally 
for  the  mammary  gland,  the  prostate,  the  mucous  membrane 
of  the  stomach,  and  the  uterus.  Of  all  organs  in  the  body  none 
illustrate  the  relation  of  cancer  to  glands  so  well  as  the  uterus, 
for  cancer  of  the  cervical  canal  is  constructed  on  the  type  of 
the  glands  normally  found  in  the  mucous  membrane  lining  it ; 
cancer  of  the  body  of  the  uterus  is  constructed  on  the  type  of 
the  uterine  glands.  Thus  cancer  of  this  organ  alone  offers 
sufficient  evidence  that  the  notion  of  cancer  in  general  con- 
forming to  three  types  must  be  cast  aside.  Even  the  most 
conservative  surgeons  will  find  little  difficulty  in  rejecting  the 
old  misleading  terminology,  for  it  has  long  been  known  that 
adenomata  absolutely  conform  in  structure  to  the  glands 
in  which  they  arise,  and  as  cancer  is  best  described  as 
malignant  adenoma,  there  will  be  little  difficulty  in  per- 
ceiving why  the  type  of  structure  is  maintained.  This 
preservation  of  the  type  of  structure  is  well  illustrated  in 
other  mammals  where  adenomata  are  also  structural  repeti- 
tions of  the  glands-  in  which  they  arise. 

A  correct  appreciation  of  the  morphology  of  adenomata 
and  carcinomata  is  of  the  first  importance  as  a  prelude  to  the 
study   of  the  cause  of -cancer.     The   ducts  of  all   secreting 

G  G 


498 


TUMOUBS. 


glands  open  on  free  surfaces  and  are  therefore  accessible  to 
minute  organisms  which  may  be  contained  in  the  air,  in  food, 
and  in  water.  It  is  therefore  conceivable  that  such  bodies 
may  gain  entrance  into  the  ducts  and  find  their  way  thence 
into  the  recesses  of  the  glands  and  give  rise  to  such  changes 
as  manifest  themselves  as  cancer.  So  far  all  this  is  problem- 
atical, for  no  one  has  succeeded  in  demonstrating  satisfactorily 


Fig.  250. — Cyst  (implantation)  of  the  palm.    (Kiimvur.) 


the  presence  of  a  specific  parasite  in  those  tumours  which  cor- 
respond to  the  definition  of  a  cancer  as  laid  down  in  this  book. 
That  parasites  find  their  way  into  glands  is  well  known — 
e.g.,  the  clemodex,  so  common  in  the  sebaceous  glands  of  the 
skin,  and  the  coccidium  oviforme,  which  infests  the  bile-ducts 
in  rabbits  and  produces  adenomatous-like  nodules  in  the  liver. 
In  this  last  case  it  would  appear  that  the  coccidia  are 
admitted  with  food  into  the  alimentary  canal,  and  invade  the 
liver  by  the  common  bile  duct.  But  there  is  this  important 
fact :  in  the  rabbit  no  one  has  demonstrated  that  these 
coccidia  nodules  become  disseminated  over  the  body  and  pro- 
duce secondary  tumours  in  the  bones,  brain,  lungs,  ovaries,  and 
elsewhere.  This  is  one  of  the  characteristic  features  of  cancer. 
To  find  a  tumour  in  the  body  of  a  vertebra,  or  in  the  shaft  ot 


THE    CAUSE    OF    TUMOUBS.  499 

the  humerus,  reproducmg  all  the  structural  features  of  a 
rectal,  thyroid,  or  prostate  gland,  is  one  of  the  most  surprising 
phenomena  in  the  whole  range  of  pathology.  The  vitality 
of  epithelium  is  very  great,  and  its  capability  of  growth 
when  transplanted  has  been  demonstratecl  experimentally  in 
addition  to  the  evidence  furnished  by  observations  on  peri- 
toneal warts  and  implantation  cysts  (Fig.  250).  We  may  be 
prepared  to  find  that  a  colony  of  tubercle  bacilli  will,  when 
lodged  in  the  calcaneum,  give  rise  to  lesions  identical  with 
those  found  associated  with  these  bacilli  in  muscles,  the 
brain,  or  lymph  glands,  as  each  of  them  contains  connective 
tissue  ;  but  to  find  a  secondary  nodule  containing  rich,  regular 
columnar  epithelium  exactly  reproducing  the  structure  of  the 
primary  tumour  in  situations  where  there  is  no  epithelium 
normally,  is  at  present  inexplicable  on  the  theory  that  cancer 
is  due  to  coccidia,  and  it  becomes  more  so  to  find  that 
secondary  nodules  of  cancer  in  the  liver  do  not  caricature  the 
hepatic  cells,  but  are  faithful  reproductions  of  the  primary 
tumour,  as  certain  as  a  fertilised  ovum,  if  it  completely 
develops,  will  reproduce  an  animal  like  to  the  animal  from 
whose  ovary  it  issued. 

There  are  many  facts  indicating  that  cancer  is  induced  by 
minute  parasites,  for  those  glands  which  are  in  most  direct 
communication  with  the  air  or  intestinal  gases  are  most 
prone  to  become  cancerous — e.g.,  the  breast,  rectum,  and 
stomach ;  whereas  cancer  of  the  prostate  and  thyroid  gland 
is,  in  England,  at  least,  rare. 

The  great  frequency  of  cancer  of  the  cervical  canal  of  the 
uterus  in  comparison  with  its  rarity  in  the  body  of  that  organ 
is  another  case  in  point.  These  are  all  significant  facts  in 
relation  to  parasitic  invasion. 

The  opinion  that  all  varieties  of  cancer  are  due  to  one 
cause  I  cannot  entertain.  Assuming  cancer  to  be  the  product 
of  such  agents  as  produce  tubercle,  glanders,  or  actinomycosis, 
it  is  much  more  probable  that  under  the  term  cancer,  even 
with  the  limitation  imposed  upon  it  in  this  book,  many 
tumours  are  grouped  together,  on  account  of  structural 
likeness,  that  have  a  widely  different  cause,  and  the  same 
view  holds  for  sarcomata  and  epitheliomata. 

Of  all  the  tumours  that  atiect  the  human  body,  the  most 


500  TUMOURS. 

mysterious  are  the  melanomata,  and  especially  those  which 
arise  in  pigmented  moles. 

I  have  not  deemed  it  necessary  to  discuss  injury  (trauma) 
as  a  cause  of  tumours.  Cohnheim  has  ably  disproved  this  in 
the  famous  lecture  on  tumours  in  his  "  Yorlesungen  liber 
allgemeine  Patholgie,"  1877-78. 

It  is  a  noteworthy  fact  that  most  pathologists  who  have 
taken  comprehensive  views  of  tumour  formation,  and  have 
made  it  the  subject  of  serious  and  prolonged  study,  are  of 
opinion  that  tumours  innocent  and  malignant  are,  in  the 
beginninsf,  local  troubles,  and  that  the  safest  and  most 
effectual  method  of  dealing  with  them  may  be  expressed  in 
one  short  sentence  :— 

Thorough  removal  of  the  tumour,  whenever  this 
is  possible,  at  the  earliest  possible  moment. 


The  End. 


INDEX   TO   :names. 


Acton,  369 
Adams,  121 
Albert,  38 
Allbutt,  C,  175 
Alsberg,  120 
Aniiandale,  43 
Arnold,  298,  316 
Arnott,  H.,  301 
Arnott,  J.  M.,  134 
Ashby,  181 


Baillie,  23 

Balding,  153 

Balfour,  392 

Baker,  M.,  362 

Barker,  121,  166,  304,  308 

Barling,  G.,  280 

Bartels,  484 

Barwell,  162 

Battle,  95,  391 

Bayer,  102 

Bayha,  214 

Beale,  C,  107 

Beck,  M.,  210 

Beevor,  179 

Bell,  Sir  Chas.,  451 

Bell,  J.,  161 

Bell,  W.,  28 

Bentlif,  21,  188 

Berger,  12 

Bergmann,  429,  435 

Bernays,  311 

Berry,  214,  241 

Billroth,  170,  206 

Bireh-Hirschfeld,  482 

Birkett,  421 

Bowlby,  20,  95,  112,  316 

Bramann,  283,  296.  429 

Braune,  318 

Broca,  35 

Brook,  S.,  47 

Brokaw,  120 

Bruns,  11,  19,  152,  162,  241 

Bryant,  160,  247,  271,  320 

Bryck,  32 

Budin,  372 

Bugnion,  367 

Butlin,  13,  92,  202,  208,  311, 


Cahen,  283 

Cameron,  123 

Carline,  481 

Cayley,  64,  182 

Chavasse,  150,  435 

Chenoweth,  123 

Cleland,  370 

Glutton,  20,  118,  284,  321 

Coats,  239,  244 

Goblenz,  399 

Cohnheim,  103,  244,  492 

Colman,  390 

Collins,    Treacher,    88,    115, 

124,  306 
Cooper,  Sir  A.,  11,  239,  299, 

374,  406,  448,  483 


Coote,  H.,  161 
Coulson,  481 
Cowell,  289,  357 
Cripps,  H.,  266 
Croft,  120 
Groom,  H.,  123 
Cruveilhier,  188,  485 
Curling,  406 
Curnow,  480 
Gusset,  312 
Guvier,  28 
Czerny,  A.,  120 


Danzel,  320 
Davies-Colley,  74 
Davis,  B.,  25 
Demours,  368 
Dickinson,  64 
Doran,  135,  277,  400 
Douty,  J.  H.,  175 
Duka,  44 
Duncan,  M.,  138,  14],  36S 


Edmunds,  189,  255 
Erichsen,  412  • 
Eve,  11,  32,  237,  407 


Fagge,  H.,  143 

Falkson,  32 

Fehmy,  11 

Fergusson,  Sir  W.,  112,   124, 

247 
Fetherston,  429 
Feurer,  293 
Finlay,  135,  238,  261 
Fischer,  120 
Flower,  Sir  W.,  56,  186 
Flover,  321 
Forster,  C,  8 
Franks,  271 


Garrod,  345 

Gay,  4 

Gee,  64 

Gervais,  P.,  28 

Gibbons,  143 

Giraldes,  301 

Glass,  382 

Godlee,  120,  285,  457 

Goodhart,  64,  179,  316 

Gould,  P.,  209 

Gowers,  14 

Graham,  474,  481 

Grawitz,  99 

Gray,  310 

Griffith,  417 

Griffiths,  J.,  77,  210,  246 

Gruber,  436 

Gurlt,  349 


Handyside,  369 
Hare,  39 
Harris,  370 


Harrison,  R.,  247 

Hart,  E.,  369 

Hawkins,  F.  H.,  267 

Heath,  34,  41 

Heusinger,  323,  326,  329,  332 

Hilaire,  G.  St.,  370 

Hildebrand,  38 

Hilton,  45 

His,  323,  336 

Hodgkin,  374 

Holt,  10 

Homans,  16 

Home,  Sir  E.,  187 

Hueter,  120,  325 

Hulke,  160,  206,  306,  343,  429 

Humphreys,  38 

Humphry,  Sir  G.,  166,  342 

Huuter,  28 

Hutchinson,  27, 107,  112,  298, 

302,  318 
Hutchinson,  Junr.,  7, 116, 149 
Huxley,  H.,  368 


Image,  160 
Irvine,  P.,  302 


Jacobson,  60,  429 
Jalland,  198 
Jessop,  120 
Jephson,  443 
Jocqs,  149 
Johnson,  R.,  312 
Jones,  11,  13 


Kanthack,  352 
Kast,  17 

Keen,  W.  W.,  251 
Keith,  S.,  121 
Kelly,  123 

Kidd,  P.,  64,  161,  249 
Klebs,  157 
Knox,  329 
Koeher,  120 
Kolaczek.  343,  390 
Konig,  120 
Kostanecki,  314,  349 


Lagrange,  215 

Lambl,  298 

Lamprey,  27,  54 

Lane,  A.,  161,  293,  432 

Langhans,  239 

Lannelongue,  292,  302 

Lawford,  88,  124 

Lawson,  G.,  89,  124,  153,  354 

Lebert,  185 

Leboucq,  297 

Lediard,  112 

Legge,  W.,  114 

Listen,  161 

Lloyd,  J.,  47,'428 

Lockwood,  4 

Leon,  Medes  de,  429 

Logan,  38 


602 


TUMOURS. 


Lucas,  C,  lis,  443,  457 
Ludlow,  435 

Macalister,  27 

Mackay,  319 

Mackenzie,  M.,  19 

Madelung,  292 

Malins,  123 

Maguire,  420,  484 

Marc,  144 

Marchand,  66,  102 

Marshall,  813 

Masse,  306 

Mathias,  37 

McCarthy,  121,  168 

McGill,  248 

Meredith,  8,  120 

Michon,  44 

Middeldorpf,  319 

Money,  A.,  64 

Mott,  v.,  54,  125 

Moore,  87 

Moore,  N.,  13,  217,  262 

Morgan,  0.  de,  153,  160 

Morris,  H.,  100,  118, 121,  243, 

384 
Moxon,  259 
Mudd,  484 
Miiller,  H.,  162 
Miiller,  J.,  1,  9 
Munde,  347 
Miu'chison,  174 
Murie,  437 
Muskett,  483 
Musser,  217 

Neumann,  101 
Niihn,  426 
Nunn,  13,  112,  235 

Obre,  14 
Ogle,  302,  485 
Oilier,  120 
Ord,  W.  M.,  320 
Ord,  W.  W.,  285 
Orlow,  26 
Osier,  76 
Owen,  E.,  12,  120 

Page,  P.,  320 

Paget,  Sir  J.,  77,  93,  326,  337 

Paget,  S.,  298,  809,  311 

Paget,  T.,  395 

Parker,  B.,  42,  311 

Parker,  R.  W.,  143 


Parono,  8 

Paul,  97,  250 

Payne,  151 

Pernice,  102 

Pick,  8 

Pitt,  N.,  77,  429 

Pitts,  271 

Pollailon,  304 

Pollard,  B.,  176,  282,  315 

Pollock,  56 

Port,  321 

Powell,  D.,  285 

Power,  D'Arcy,  13,  282 

Power,  H.,  306 

Prudden,  102 

Pughe,  120 


Ranke,  11 

Ransom,  484 

Rasch,  429 

Ratlike,  323 

Rawdon,  120 

Recklinghausen,  14,  17,  159, 

247 
Reclua,  203 
Reid,  25 
Reisinger,  66 
Beverdin,  240 
Ribbert,  97 
Richet,  309 
Rindfleiscli,  251 
Ris,  121 

Rokitansky,  436 
Roser,  390 
Roth,  891 


Scliulz,  64 

Schwalbe,  332 

Schweizer,  239 

Senn,  429 

Sharkey,  66,  256 

Shattock,  236,  254,  304,  334, 

373,  395 
Sheild,  474 
Sibley,  S.,  150 
Sibley,  W.  K.,  316 
Sibthorpe,  300 
Silfiock,  247,  455 
Sims,  38 
Smith,  151,  156 
Smith,  N.,  290 
Smith,  T.,  13,  457 
Solly,  463 
Stanley,  222 
Steinheil,  4 


Steudel,  18 
Strahau,  179 
Streckcisein,  314 
Stuart,  A.,  333 
Szabo,  123 


Tait,  396 
Targett,  102 
Taylor,  P.,  13,  179, 
Taylor,  57,  120 
Teilander,  86 
Temoin,  14 
Thomas,  481 
Thornton,  99,  121,  123 
Tomes,  Chas.,  87,  39,  42 
Tomes,  Sir  J.,  87,  89 
Toynbee,  150 
Travers,  482 

Treves,  8,  56,  119,  271,  304 
Trousseau,  447 
Tsander,  128 
Tuckerman,  366 
Turner,  Sir  W.,  25,  302 


Verco,  485 

Virehow,  1,  10, 17,  56,  63, 143, 
256,  828,  450,  464,  473 


Wagner,  128 

Walsham,  18,  120,  327 

Wardrop,  355 

Watson.  30 

Webb,  481 

Webb,  W.,  45 

Weichselbaum,  20 

Welcker,  25 

Wells,  Sirs.,  16,  121,141 

Wesner,  148 

Whipham,  64 

White,  H.,  284,  298,  316 

Whitehead,  121 

Wild,  280 

Wilks,  S.,  259,  291 

Williams,  J.,  212,  277 

Windle,  38 

Witsenhausen,  210,  239 

Wolf,  311 

Wood,  50 

Worner,  157 

Wright,  56 

Wright,  G.  A.,  458 


Zahn,  806 
Zenker,  102 


IKDEX    TO     OEQAXS. 


Adrenal — 

hydatids  of,  482 
/    tumours  of,  98 
Adrenals,  accessory — 

tumours  of,  99 
Adrenal  goitres,  99 

Bartholin's  Glands — 

adenoma  of,  239 
carcinoma  of,  239 
cysts,  239 
Bladder — 

diverticula,  431 
epithelioma,  210 
mj^oma,  143 
papilloma,  172 
villous  tumours,  172 
Brain — 

glioma  of,  63 
hj^datids,  483 
hydrocephalus,  445 
meningocele,  451 
neuroma,   157 
papilloma,  175 
psammoma,  177 
sarcoma,  78 
Bone — 

chondroma  of,  17 
hydatids  of,  480 
femur,  482 
humerus,  474,  481 
ilium,  482 
lipoma  of,  13 
osteoma  of,  23 

auditory  meatus,  24 

frontal,  24 

maxilla,  24,  27 

vertebra,  25 
phalanx,  482 
sarcoma  of,  78 

clavicle,  82,  118,  125 

femur,  81,  82 

fibula,  80,  82 

humerus,  82 

ilium,  82 

mandible,  83 

maxilla,  83 

radius,  82 

ribs,  82 

scapula,  82 

skull,  82 

sternum,  82 


Bone  {continued). 

tibia,  82 

ulna,  82 
sarcoma  (myeloid)  — 

clavicle,  118,  125 

mandible,  85 

maxilla,  85 

radius,  118 

ulna,  118 
tibia,  481 
vertebrae,  485 
Breast  {see  Mamma) 

Cicatrix — 

epithelioma  of,  213 

horns  of,  187 

keloid  of,  56 
Clitoris — 

epithelioma,  211 
Colon — 

carcinoma  of,  264,  207 
Conjunctiva — 

angeioma  of,  158,  337 

dermoid  patches,  355 

epithelioma,  214 

lipoma,  11 

moles,  355 
Cowper's  Gland — 

carcinoma  of,  239 

Digits — 

bursa,  443 

chondroma,  18 

dermoids,  304 

hydatids,  482 

lipoma,  4 

melanoma,  112 
Ducts — 

functionless,  389 

obsolete,  308 
Dura  mater — 

dermoids  of,  302 

Eyeball- 
carcinoma,  115 
cysts  (of  cornea),  306 
cysts  (of  iris),  305 
dermoids,  355 
epithelioma,  214 
glioma  {see  Sarcoma) 
melanoma,  112 
sarcoma,  87,  112 


504 


TUMOURS. 


Eyelid— 

coloboma,  29o,  357 
dermoids,  294 
riEcvi,  158 

Face— 

angeioma,  158 
dermoid,  2S7 
epithelioma,  191 
fissures,  287 
keloid,  56 
moles,  353 

mandiljular  tubercles,  289 
Fallopian  tube — 
adenoma,  276 
carcinoma,  276 
cysts,  376-37S 
myoma,  142 

Gall  bladder — 

epithelioma,  215 
hydrocholecyst,  385 
pyocholecyst,  386 
Gums — 

epithelioma,  200 
fibroma  (epulis),  49,  84 
sarcoma,  84 

Hands — 

chondroma,  18 

cysts  (implantation)  304 

synovial,  439 

ganglion,  440 
lipoma,  4 
melanoma,  112 
neuroma,  149 
sarcoma,  82 
Heart — 

hydatids,  479 
lipoma,  13 

Intestine — 

adenoma,  263 
carcinoma,  267 
diverticula,  431 
fibroma,  62 
lipoma,  8 
myoma,  143 
sarcoma,  78 

Jaws — 

epithelioma,  200 
epithelioma  (boring),  203 
exostosis,  27 
fibroma  (epulis),  49 
odontoma,  31 
sai'coma  (antrum),  84 

(of  tooth  follicle),  85 

(iDcriosteal),  84 

(myeloid),  85 


Joints — 

hydatids,  482 

lipoma,  9 

loose  bodies  (chondromata),  20 

synovial  cysts,  437 

Kidney  — 

adenoma,  252 
carcinoma,  256 
congenital  cj-sts,  252 
hydatids,  473,  480 
hydronephrosis,  378 
papilloma,  174 
pyonephrosis,  385 
sarcoma,  96 

Labium — 

adenoma  (Bartholin's  glands),  239 

angeioma,  158 

cysts  (sebaceous),  234 

epithelioma,  211 

lipoma,  7 

myxoma,  61 

papilloma  (warts),  168 
Lachrymal  gland — 

chondroma,  92 

dacryops,  429 
Larynx^ 

angeioma,  161 

diverticula,  423 

epithelioma,  205 

fibroma,  52 

lipoma,  10 

Ij-mpho-sarcoma,  107 

j)apilloma  (warts),  171 
Lips — 

angeioma,  158 

cysts  (mucous),  238 

dermoids,  292 

epithelioma,  197 

lymphangeioma,  165 
Liver — 

adenoma,  250 

angeioma,  161 

carcinoma,  251 

dermoids  (secondary),  343 

hydatids,  476 
Lungs — 

carcinoma,  238 

hydatids,  479 

sarcoma  (secondary),  72 

Mamma — 

adenocele,  221 
adenoma,  221 
angeioma,  159 
carcinoma  (acinous),  222 
carcinoma  (duct),  228 
chondro-sarcoma,  94 
cysts  (involution),  228 


INDEX    TO    ORGANS. 


505 


Mamma  {continued). 

hydatids,  482 

sarcoma,  94 
Mucous  membrane — 

angeioma,  160 

dermoids,  297,  321 

diverticula,  431 

epithelioma,  200 

moles,  355 

myoma,  129 

myxoma,  59 

papilloma,  171 

sarcoma,  78 
Muscles — 

angeiom.a,  160 

sarcoma,  73 

Nerves- 
neuroma,  147 
sarcoma,  153 

Omentum — 

colloid  disease,  26 1 

cysts,  342,  428 

dermoids,  342 

hydatids,  483 
(Esophagus — 

diverticula,  435 

carcinoma,  260 

epithelioma,  203 

myoma,  143 

papilloma,  171 
Orbit— 

hydatid,  483 

lipoma,  11 

myosarcoma,  102 

neuroma,  149 

osteoma,  30 

sarcoma,  89 
Ovary — 

adenoma,  257,  339 

carcinoma,  257 

cysts,  339 

dermoid,  340 

fibroma,  52 

hydrocele,  415 

myoma,  141 

papilloma,  399 

sarcoma,  94,  123 

Palate— 

Adenoma,  298 
dermoid,  297 
epithelial  pearls,  350 
epithelioma,  200 
moles,  298 
sarcoma,  84 
Pancreas — 
carcinoma,  248 


Pancreas  {continued). 

cysts,  426 

sarcoma,  92 
Parotid  gland- 
adenoma,  248 

carcinoma,  248 

chondro-sarcoma,  90 

cysts  (ranula),  425 

sarcoma,  90 
Penis  — 

carcinoma,  237 

epithelioma,  208 

horns,  184 

papilloma,  168 
Parovarium — 

cysts,  400 
Pinna — 

cysts  (sebaceous),  338 

dermoids,  337 

epithelioma,  206 

fistula  (sinus),  337 

horns,  172 

keloid,  56 
Pituitary  body — 

adenoma,  316 

cysts  (infundibulum),  316 

dermoids,  316 
Prostate — 

adenoma,  246 

carcinoma,  247 


Rectum — 

adenoma,  263 
angeioma,  160 
carcinoma,  264 
dermoids,  321 
polypus,  263 
Retina  {see  Eyeball).. 
sarcoma,  87 


Sacrum — 

dermoids,  280 
hydatids,  482 
lipoma,  14 
spina  bifida,  460 
teratoma,  366,  368 
Scalp — 

angeioma,  163 
cephalhydrocele,  457 
cephalhsematoma,  454 
dermoids,  299 
horns,  185 
lipoma,  6 
meningocele,  451 
myoma,  144 
moUuscum  fibrosum,  57 
sebaceous  cysts,  233 
sebaceous  adenoma,  236 


506 


TUMOURS. 


Scrotum — 

dermoids,  282 

epithelioma,  207 

horns,  185 

hydatids,  483 

hydrocele,  411 
.     lipoma,  7 

myoma,  144 
Skin- 
adenoma  (sebaceous),  236 

angeioma,  158 

cysts  (sebaceous),  231 

dermatolysis,  53 

dermoids,  279 

epithelioma,  213 

fibi'oma,  moUuscum,  53,  150 

fibroma,  simple,  50 

horns,  183 

keloid,  56 

lipoma,  3 

lymphangeioma,  164 

melanoma,  110 

moles,  353 

myoma,  144 

myxoma,  60 

papilloma,  168 

sarcoma,  78 
Spinal  column — 

half-vertebra,  470 

hydatids,  485 

lijDoma,  14 

osteoma,  25 

sarcoma,  82 

spina  bifida,  459 
Spinal  cord — 

glioma,  65 

lipoma,  14 

myxoma,  150 

psammoma,  181 

sarcoma,  78 
Stomach — 

adenoma,  259 

carcinoma,  259 

lipoma,  10 

myoma,  143 
Subserous  tissue — 

angeioma,  161 

hydatids,  483 

lipoma,  6 

myoma,  131,  139 


Teeth- 
fibroma  (ejjulis),  49 

odontomc,  31 

sarcoma,  85 
Testicle — 

adenoma,  257,  406 

carcinoma,  257 

chondro- sarcoma,  93 

dermoids,  282 

hydrocele,  411 

myo-sarcoma,  101 

sarcoma,  107 
Thyroid  gland — 

accessory  thyroids,  241,  314 

adenoma,  240 

bronchocele,  240 

carcinoma,  241 

cysts,  240 

hydatids,  482 
Tongue — 

angeioma,  160 

dermoids,  308 

epithelioma,  199 

ichthyosis,  199 

lipoma,  11 

lymphangeioma  (macroglossia),  165 

lympho-sarcoma,  106 

sarcoma,  106 
Tonsil— 

epithelioma,  200 

lympho-sarcoma,  106 

Uterus — 

adenoma,  272,  275 
carcinoma,  273,  275 
epithelioma,  212 
hydatids,  483 
myoma,  126 
polypi  (myomata),  129 
sarcoma,  102 
Uveal  tract — 

melano-carcinoma,  115 
melano- sarcoma,  112 

Vagina — 

cysts,  402 
epithelioma,  211 
myo-sarcoma,  102 
Vermiform  appendix — 

hydatids,  482 


I^DEX    TO    TUMOUES. 


Adenoma — 

characters  of,  218 
species  of,  219 
Fallopian,  276 
gastric,  259 
hepatic,  260 
intestinal,  263 
mammarj^,  221 
ovarian,  257,  339 
parotid,  248 
prostatic,  246 
rectal,  263 
renal,  252 
sebaceous,  236 
thyroid,  240,  314 
uterine  cavity,  275 
uterine  cervix,  272 
Angeioma^ 

characters  of,  158 
species  of,  158 

cavernous,  159 

nsevus,  158 

plexiform,  161 
treatment  of,  163 
arm,  162 
of  brain,  63 
of  breast,  159 
of  conjunctiva,  158,  337 
of  face,  158 
of  labium,  158 
of  larynx, 161 
of  lip,  158 
of  liver,  161 
of  mamma,  159 
of  mucous  membrane,  160 
of  muscles,  160 
of  rectum,  160 
of  skin,  158 
of  subserous  tissue,  161 
of  tongue,  160 

Bursse,  characters  of,  441 
varieties  of,  442 

bunion,  443 

digital,  -^43 

ischiatic,  442 

malleolar,  442 

prepatellar,  442 

stumps,  443 

thyro-hyoid,  443 

trochanteric,  443 
treatment  of,  443 


Cancer  (carcinoma),  219 
characters  of,  219- 
dissemination  of,  220 
species  of,  220 

breast,  222 

ciliary,  115 

gastric,  259 

hepatic,  251 

intestinal,  267 

mammarj^,  222 

ovarian,  257 

pancreatic,  248 

parotid,  248 

prostatic,  247 

rectal,  264 

renal,  256 

sebaceous,  237 

testis,  257 

thyroid,  241 

uterine  cavity,  275 

uterine  cervix,  273 
Chondroma,  characters  of,  17 
classification  of,  17 
species  of,  17 

chondroma,  17 

ecchondroses,  18 

loose  cartilages,  20 
of  bones,  17 
of  cartilage,  18 
of  joints,  20 
of  larj'nx,  1 8 
Chondro- sarcoma  {see  Sarcoma) 
Cysts,  characters  of,  376 
classification  of,  376 
species  of 

allantoic,  395 

chyle-cysts,  429 

dacryops,  429 

Gartnerian,  402 

hydroceles,  411 

hydrocholecyst,  385 

hydrometra,  377 

hydronephrosis,  378 

hydrosalpinx,  376,  418 

Miillerian,  409 

pancreatic,  426 

paroophoritic,  397 

parovarian,  400 

ranula,  425 

testicular,  403,  406 

tubulo-cysts,  389 

vermiform  appendix,  377 


608 


TUMOURS. 


Cysts  {continued) . 

vitello-intestinal,  389 
of  cornea,  306 
finger,  304 
iris,  305 
kidney,  378 
labium,  239 
lachrymal  gland,  429 
mamma,  228 
neck,  327,  419 
ovary,  339 
pancreas,  426 
parotid,  425 
pharynx,  316,  432 
skin,  233 

spinal  column,  459 
testicle,  403 
thyroid  gland,  240 

Dermoids,  characters  of,  279 

classification,  279 

genera  of,  279 

dermoid  patches,  353 
ovarian  dermoids,  339 
sequestration  dermoids,  279 
tubulo-dermoids,  308 

treatment  of,  359 

of  back,  279 

coccyx,  318 

conjunctiva,  355 

dura  mater,  302 

face,  287,  353 

fingers,  304 

hand,  304 

inguinal  canal,  282 

lips,  291 

liver,  343 

neck,  327 

orbit,  293 

ovary,  339 

palate,  297 

pharynx,  326 

pinna,  335 

pituitary  body,  31G 

rectum,  321 

sacrum,  280 

scalp,  299 

scrotum,  282 

spine,  279 

sternum,  283 

testicle,  282 

thorax,  283 

tongue,  308 
Diverticula,  chai-acters  of,  431 

classiflcation,  376 

ganglion,  440 

intestinal,  431 

oesophageal,  435 

pharyngeal,  327,  432 

synovial,  437 


Diverticula  (continued). 

tracheal,  435 

vesical,  431 
Diverticulum,  trachea  of  emu,  436 

Epithelial  Pearls — 

dermoids,  350 

ovary,  351 

penis,  351 
Epithelioma,  191 

boring,  203 

characters  of,  191 

course  of,  194 

dissemination  of,  196 

lymph  glands  in,  195 

mode  of  origin,  192 

terminations  of,  195 

treatment  of,  196 

varieties  of,  192,  203 

of  anus,  213 

of  bladder,  210 

of  cheek,  200 

of  clitoris,  211 

of  conjunctiva,  214 

of  gall-bladder,  215 

of  gums,  200 

of  labium,  211 

of  larynx,  205 

of  lips,  197 

of  mouth,  200 

of  oesophagus,  203 

of  palate,  200 

of  penis,  208 

of  pharynx,  200 

of  pinna,  206 

of  scars,  213 

of  scrotum,  207 

of  skin,  213 

of  tongue,  199 

of  tonsil,  200 

of  urethra,  209 

of  uterine  cervix,  212 

of  vagina,  211 
Epithelioma  and  horns,  184 
Exostosis — 

of  femur,  26 

of  fish,  28 

maxilla,  27 

subungual,  27 

Fibroma,  characters  of,  49 

classification,  50 

species  of 

neuro-fibroma,  147 
moUuscum  fibrosum,  53 
simple  fibroma,  50 

of  gum  (epulis),  52 

of  intestine,  52 

of  larynx,  52 

of  ovary,  52 


INDEX    TO     TUMOURS. 


509 


Fibroma  {euntimied) . 
of  skin  (keloid),  oQ 
of  uterus,  52 

Glioma,  characters  of,  63 

of  cerebrum,  63 

crura  cerebri,  64 

medulla,  64 

pons,  64 

retina  [see  Sarcoma) 

sjDinal  cord,  65 
Guttural  pouches  of  horses,  387 

Hair-fields,  467 
Horns,  cutaneous,  183 
varieties  of,  183 
cicatrix,  187 

nail,  189 

sebaceous,  183 

wart,  184 
Hydatids — 

characters  of,  472 
distribution  of,  475 

geographical,  475 

topographical,  475 

zoological,  475 
treatment  of,  485 
varieties  of,  473 

colonies,  473 

multilocular,  473 

sterile  cysts,  473 
Hydatid  rash,  478 
Hydatids  of  adrenal,  482 
of  bones,  480 
of  brain,  483 
of  breast  {see  Mamma) 
of  connective  tissue,  483 
of  heart,  479 
of  joints,  482 
of  kidney,  473,  480 
of  liver,  476 
of  lung,  479 
of  mamma,  482 
of  mesentery,  483 
of  meso-colon,  483 
of  meso-rectum,  483 
of  omentum,  483 
of  orbit,  483 
of  pelvis,  483 
of  pericardium,  477 
of  pei'itoneum,  477 
of  pleura,  477 
of  scrotum,  483 
of  spinal  canal,  484 
of  subserous  tissue,  483 
of  thyroid  gland,  482 
of  tunica  vaginalis,  483 
of  uterus,  483 

of  vermiform  appendix,  482 
of  vertebraj,  485 


Hydroceles,  classification  of,  376,  411 
canal  of  Xuck,  415 
congenital,  414 
encysted,  403 
fourth  ventricle,  450 
funicular,  414 
hernial  sac,  415 
neck,  419 
ovary,  415 
tunica  vaginalis,  411 
treatment  of,  415 

Ichthyosis  of  the  tongue,  199 

Keloid,  56 

Lipoma,  characters  of,  3 
classification  of,  3 
treatment,  16 
species  of,  3 

intermuscular,  11 

intramuscular,  13 

meningeal,  14 

parosteal,  13 

subcutaneous,  3 

submucous,  10 

subserous,  6 

subsynovial,  9 
arborescens,  9 
of  axilla,  5 
of  bones,  10 
of  broad  ligament,  8 
of  fingers,  4 
of  foot,  4 
of  hand,  4 
of  heart,  13 
of  hernial  sacs,  6 
of  jejunum,  10 
of  joints,  9 
of  labium,  7 
of  larynx,  10 
of  muscles,  13 
of  neck,  7 
of  orbit,  1 1 
of  periosteum,  13 
of  sacrum,  14 
of  scrotum,  7 
of  skin,  3 

of  spinal  column,  14 
of  spinal  cord,  14 
of  stomach,  10 
of  subserous  tissue,  6 
of  subsynovial  tissue,  9 
of  tongue,  1 1 
Lymphangeioma,  164 

Myoma,  characters  of,  126 
treatment,  144 
of  bladder,  143 
of  broad  ligament,  139 


510 


TUMOURS. 


Myoma  (oontinucd). 
of  Fallopian  tube,  142 
of  intestines,  143 
of  oesophagus,  143 
of  ovarian  ligament,  141 
of  ovary,  141 
of  skin,  144 
of  stomach,  143 
of  uterus,  126 
varieties  of,  126 

intramural,  127 

submucous,  129 

subserous,  131 
Myxoma,  characters  of,  59 
classification,  59 
species  of 

aural  polypus,  60 

cutaneous  myxoma,  60 

neuro-myxoma,  147 
treatment  of,  61 
myxomatous  disease  of  chorion,  61 

Neural  Cysts,  445 

hj'-drocele  of  fourth  ventricle,  450 
hydrocephalus,  445 
meningocele  (cranial),  451 
spina  bifida,  459 

classification  of,  460 

treatment  of,  469 
Neuroma,  characters  of,  147 
classification,  147 
treatment  of,  156 
species  of 

neuro-fibroma,  147 

plexiform,  151 

traumatic,  154 
of  auditory  nerve,  149 
of  brain,  157 
of  facial  nerve,  148 
of  fifth  nerve,  149 
of  infraorbit  nerve,  148 
of  musculo-sjHral  nerve,  152 
of  optic  nerve,  149 
of  radial  nerve,  149 
of  sciatic  nerve,  153 
of  stumps,  154 
malignant,  153 
ganglionic,  157 

Odontomes — 

classification,  31 
treatment,  48 
species  of 

cementome,  34 

compound,  36 

composite,  41 

epithelial,  31 

fibrous,  33 

follicular,  32 

radicular,  38 


Osteoma,  characters  of,  23 

classification,  23 

treatment,  28 

species  of,  23 
cancellous,  25 
compact,  23 

of  auditory  meatus,  24,  30 

of  frontal  sinus,  23 

of  odontoid  jDrocess,  25 

of  orbit,  23,  30 
Painful  subcutaneous  tubercle,  50 

Papilloma,  characters  of,  168 
classification,  167 
sj)ecies  of 

cutaneous,  167 

intracystic,  173 

psammoma,  177 

villous,  172 
of  skin,  168 
of  larynx,  171 
of  oesophagus,  171 
of  peritoneum,  398 
of  pia  mater,  175 
of  renal  iDclvis,  174 
Post-anal  dimples,  280 
Precancerous  conditions,  199 
Psammoma — 

of  fourth  ventricle,  178 

lateral  ventricle,  179 

spinal  membrane,  181 
Pseudo- cysts,  characters,  431 
classification  of,  376 
genera  of 

bursas,  441 

diverticula,  431 

hydatids,  472 

neural  cysts,  445 

Sarcoma- 
characters  of,  67 
classification  of,  67 
malignancy  of,  67 
treatment  of,  117 
species  of 

alveolar,  70 

lympho-,  68,  104 

melano-,  71,  108 

myeloid,  70,  85,  118 

round-celled,  67 

spindle-celled,  68 
varieties  of  spindle-celled 

chondro-sarcoma,  70,  90,  94 

fibro-sarcoma,  70 

myo-sarcoma,  70,  96 
of  bone,  78 
of  breast,  94 
of  digits,  112 
of  eyeball,  r57,  112 
of  gum,  84 


INDEX     TO     TUMOURS. 


511 


Sarcoma  ( continued ) . 
of  jaw,  83 
of  kidney,  96 
of  larynx,  106 
of  mamma,  94 
of  mediastinum,  104 
of  muscles,  73 
of  nasal  septum,  86 
of  naso-pharynx,  86 
of  nerves,  153 
of  ovary,  94 
of  parotid,  90, 
of  retina,  87 
of  skin,  110 
of  teeth,  85 
of  testicle,  92 
of  thyroid,  77 
of  tongue,  106 
of  uterus,  102,  135 
of  uveal  tract,  112 


102 


10/ 


Sarcoma  {continued). 

of  veins,  74 

of  vagina,  102 
Spina  bifida — 

complications  of,  487 
species  of,  460 
masked,  464 
meningocele,  462 
meningo-myelocele,  461 
myelocele,  460 
occulta,  464 
syringo-myelocele,  46 1 
treatment  of,  469 


Tails,  471 
Teratoma — 

acardiacs,  371 
conjoined  twins,  363 
parasitic  acardiacs,  364 


Printed  by  Cassell  &  Companv,  Limited,  La.  Belle  Sauvage,  London,  E.C. 


_    ■.■^.A  „'.;VERS1TY  LIBRARIES  (hsi.stx) 

RD  651  B61  C.1 


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